Nondisplaced fractures are likely inherently stable and can be treated with removable bracing for protection.

Closed reduction and splinting is indicated as the initial management for all displaced distal radius fractures presenting to the emergency room.

Although controversial, evidence suggests that lower demand and/or elderly patients with mild residual deformity after closed reduction may still do well with nonoperative management in a cast.

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  The American Academy of Orthopaedic Surgeons (AAOS) guidelines are unable to recommend for or against operative treatment in patients older than 55. ¹¹

  
  
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  Chung et al found elderly patients tend to do well with either open reduction internal fixation (ORIF) or casting; however, ORIF was estimated to be seven times more expensive. ¹²

Casting techniques: The Cotton-Loder position of wrist flexion and ulnar deviation should be avoided as this has been shown to increase carpal tunnel pressure.

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  Gelberman et al showed increasing carpal tunnel pressure to 47 mmHg at 40 degrees of wrist flexion. ¹³

The AAOS guidelines recommend weekly radiographic follow-up for 3 weeks after injury to evaluate for fracture displacement. ¹¹

In young patients with extra-articular fractures, pinning alone is an option.

Trumble et al demonstrated good results with pinning in fractures with comminution of only one cortex in young patients. Supplementary external fixation was required if comminution extended to two or more cortices. ¹⁴

In older patients with extra-articular and/or minimally displaced intra-articular fractures, pinning is also an option; however, it requires supplemental external or internal fixation. ¹⁴

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  External fixation or internal bridging plate depends on the ligamentaxis to hold reduction. ¹⁵

Agee helped to popularize the idea of using an external fixator to achieve fracture reduction via multiplanar ligamentotaxis. ¹⁵

External fixation is often useful in situations with significant soft tissue compromise, polytrauma, highly comminuted articular fractures, etc.

Hanel et al popularized bridge plating to act as an internal fixator (vs. external) for distal radius fractures. ¹⁶

Indications include high energy fractures with extension into the radial metaphysis and polytrauma patients requiring early use of the upper extremities.

Although the original technique involved using a 3.5-mm plate on the floor of the 4th dorsal compartment to the 3rd metacarpal, ¹⁷ Hanel et al published a modification using either a Synthes 2.4 mm distal radius bridge plate or mandibular reconstruction plate through the 2nd dorsal compartment to the 2nd metacarpal (► Fig. 8.2). ¹⁶

The bridge plate functions as an internal fixator, reducing the fracture through ligamentotaxis.

Advantages include reducing the need for nursing care of pin site tracts on external fixators, relatively short operative time, and a stable wrist to allow early use of the upper extremity.

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  Immediate weight bearing through the forearm and elbow is permissible with a platform walker followed by transition to hand grip crutches at 1 month or so.

The plate is removed after fracture consolidation, an average of 112 days in Hanel’s series. ¹⁶

In the 1990s, Orbay introduced locked volar plating as an alternative to the more common dorsal plating at the time. ¹⁸ This was quickly adopted given the high rate of extensor tendon irritation/ruptures seen with dorsal plating.

Volar plating has demonstrated improved functional results in the early postoperative period with few complications compared to other treatment methods. ¹⁹

Indications including unstable distal radius fractures, open fractures, and fractures failing nonoperative management.

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  The AAOS guidelines recommend operative fixation of fractures with postreduction radial shortening >3 mm, dorsal tilt >10 degrees, or intra-articular displacement/ step-off >2 mm. However, the guidelines do not recommend for or against any specific type of operative treatment. ¹¹

Approach to the distal radius (Video 8.1)

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  The fracture is most commonly accessed via the modified Henry approach to the distal radius, utilizing the interval between the median nerve/carpal tunnel contents and the radial artery—through the floor of the flexor carpi radialis sheath

  
  
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  This incision may be extended to further open the carpal tunnel should decompression be required.

  
  
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  The radial artery and the superficial branch of the medial nerve are at risk.

  
  
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  Although effort should be made to repair the horizontal limb of the pronator quadratus exposure in order to cover the plate, there were no differences in range of motion (ROM), grip strength, and postoperative complications in a series by Ahsan et al ²⁰ which evaluated repair versus no repair of the pronator quadratus (PQ).

Reduction techniques

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  In the operating room, the reduction maneuver of Agee can be utilized to recreate radial height, volar tilt, and intra-articular step-off via ligamentotaxis. ²¹

  
  
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  Reduction maneuver involves traction, volar translation, and pronation.

  
  
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  Should the reduction be unstable, it can be pinned with K-wires aimed proximally through the radial styloid.

  
  
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  Additionally, weighted traction can be applied with finger traps off the edge of the table to provisionally hold the reduction while the plate is applied.

  
  
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  The plate itself can be used as a reduction tool to restore volar tilt as well. The plate is first attached distally such that the proximal portion sits off the radial diaphysis. Then bringing this proximal plate down to bone will tilt the articular surface volarly—“Lift-off” technique.

Outcomes

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  Open reduction and internal fixation with volar fixed angle plating has been shown to provide a stable reduction and allow for earlier ROM. ²²

  
  
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  ORIF has also been shown to provide a quicker return to function. ¹⁹

Fragment-specific fixation has shown to be a viable alternative to other forms of fixation in certain instances. ²³

The benefits of this approach include versatile fixation that can be tailored to specific fracture patterns and strong fixation that allows for early postoperative ROM. ²³ , ²⁴

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  Fragment-specific fixation has been shown to provide stronger fixation of volar ulnar corner fragments biomechanically. ²⁵

Drawbacks include an initial learning curve that may increase operative times and hardware irritation. ²³ In addition, missed fragments may result in an unstable fixation, highlighting the need for careful preoperative planning.

Principles

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  There are five primary fracture elements that need to be addressed, namely, radial column, ulnar corner, volar rim, dorsal wall, and impacted articular fracture fragments. ²⁶

  
  
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  Commonly available pin and plate configurations include ²⁶ , ²⁷ volar pin plates, ulnar pin plates, radial pin/column plates, dorsal/volar buttress clip pins, and dorsal/volar radial hook plates.

  
  
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  Plates are placed in an orthogonal position to increase strength. ²⁴ , ²⁶

  
  
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  The focus is on anatomic articular reduction. ²⁴

  
  
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  Metaphyseal defects are filled with bone graft in order to prevent loss of radial length. ²⁴

  
  
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  Small fragments may not need specific fixation if large fragments are fixed around them to hold in place.

  
  
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  Wrist ROM should be started early to prevent postoperative stiffness. ²⁴ , ²⁶

Approaches:

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  Volar approach: ²⁶ , ²⁷

  
  
  
  
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    Although the extended flexor carpi radialis (FCR) approach allows access to the entire volar surface of the distal radius, more limited approaches may be used as well depending on the fracture pattern.

    
    
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    Limited-incision volar approach: Utilizes interval between radial artery and brachioradialis to gain access to the volar radial aspect of the distal radius.

    
    
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    Volar ulnar approach: Utilizes the interval between the flexor carpi ulnaris (FCU) and the flexor digitorum profundus (FDP) tendons to gain access to the volar ulnar corner of the distal radius.

  
  
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  Dorsal approach:

  
  
  
  
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    A standard 3rd compartment splitting approach may be utilized to view the entire dorsal surface of the radius if needed. Alternatively more limited approaches can be used.

    
    
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    Interval between the 3rd and 4th extensor compartments can be used to access the dorsal wall.

    
    
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    Interval between the 4th and 5th compartments can gain access to the dorsal ulnar corner as needed.

Medoff suggests a stepwise operative approach that involves: ²⁶

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  Restoring radial column length.

  
  
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  Fixing the volar rim.

  
  
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  Reducing and fixing any dorsal or free articular components to the previously fixed volar rim, using bone graft as needed for defects.

  
  
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  Fixing with a radial column plate to maintain length.

Contraindications ²⁴

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  Fracture fragment extension into the radial diaphysis is an absolute contraindication.

  
  
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  Relative contraindications include very poor quality bone and large metaphyseal defects.