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Dual Radial Styloid and Volar Plating for Unstable Fractures of the Distal Radius

March 29, 2018 | Surgery
Matthew R. Garner, MD ; Patrick C. Schottel, MD ; Ryan R. Thacher, BA ; Stephen J. Warner, MD, PhD ; Dean G. Lorich, MD†
Author and Disclosure Information

Authors’ Disclosure Statement: The authors report no actual or potential conflict of interest in relation to this article.

Acknowledgment: The authors would like to convey that this article is in dedication and in tribute to the life and career of Dean G. Lorich, MD.

Dr. Garner is an Assistant Professor, Milton S. Hershey Medical Center and Penn State College of Medicine, Hershey, Pennsylvania. Dr. Schottel is an Assistant Professor, University of Vermont Medical Center, South Burlington, Vermont. Mr. Thacher is a Medical Student, Columbia University College of Physicians and Surgeons, New York, New York. Dr. Warner is an Assistant Professor, University of Texas Health Science Center at Houston, Houston, Texas. Dr. Lorich was Associate Director of Orthopaedic Trauma Service, Hospital for Special Surgery; and Associate Professor of Orthopaedic Surgery, New York Presbyterian Hospital, Weill Cornell Medical College, New York, New York.

†Died December 10, 2017.

Address correspondence to: Matthew R. Garner, MD, Milton S. Hershey Medical Center, 500 University Drive, Hershey, PA 17033 (tel 717-531-1363; email, Mgarner3@pennstatehealth.psu.edu).

Am J Orthop. 2018;47(3). Copyright Frontline Medical Communications Inc. 2018. All rights reserved.

Matthew R. Garner, MD Patrick C. Schottel, MD Ryan R. Thacher, BA Stephen J. Warner, MD, PhD Dean G. Lorich, MD† . Dual Radial Styloid and Volar Plating for Unstable Fractures of the Distal Radius. Am J Orthop. March 29, 2018

TAKE-HOME POINTS

  • Radial column fixation can be used as a reduction tool in unstable distal radius fractures. 
  • Radial column fixation can help maintain reduction until union in unstable distal radius fractures when combined with volar plating.
  • When operating without an assistant, radial column plating can assist in reduction maintenance when other techniques are not successful and holding a reduction manually is not possible.
  • Acceptable clinical and radiographic outcomes can be achieved with the use of dual radial styloid and volar plating for unstable distal radius fractures. 
  • The effects of increased dissection during radial column fixation in distal radius fractures with regard to scar formation and wrist ROM is currently not known.

Distal radius fractures are among the most common orthopedic injuries encountered; their reported incidence is >640,000 annually and is estimated to increase.1-4 The management of these injuries has evolved from closed reduction and casting to percutaneous pinning and internal fixation, as the importance of achieving and maintaining an anatomic reduction has become more apparent.5-7 More recently, volar locking plates have emerged as a way to prevent complications associated with dorsal plating. Most authors agree that volar locked plating achieves stable fixation and allows for early postoperative wrist range of motion (ROM).5,8-11 However, a volar approach to a dorsally unstable fracture creates difficulty with regard to reduction at the time of surgery and several reports have noted mechanical failure with utilization of locked volar plating alone.12-15

Dual plating of unstable distal radius fractures with a volar locking plate and a radial column plate has been described in the past in the setting of severely comminuted fractures or in patterns with a large radial styloid fragment that was not addressed with a volar locking plate alone.16-19 The purpose of this study is to present the use of the radial column plate as a tool that allows a surgeon to achieve and maintain reduction during open reduction and internal fixation (ORIF) of an unstable distal radius fracture.

OPERATIVE TECHNIQUE

Patients for whom ORIF is indicated include those with unstable distal radius fractures, with or without intra-articular extension and involvement of both the intermediate and lateral columns.

The patient is positioned supine on the operating table with the operative hand placed palm-up on a radiolucent hand table. A volar approach to the distal radius is undertaken, utilizing the interval between the flexor carpi radialis (FCR) tendon and the radial artery. The floor of the FCR sheath is incised, and a self-retaining retractor with blunt tips can be placed to permit visualization. The pronator quadratus (PQ) is sharply reflected off the radial boarder of the distal radius and approximately 1 mm to 2 mm proximal to the radiocarpal joint with an L-shaped incision for fracture site exposure. The brachioradialis is then identified and tenotomized with a scalpel (Figure 1).

Clinical image of brachioradialis tenotomy using a scalpel during exposure of the distal radius

A preliminary reduction is then performed using a combination of axial traction and palmar translation of the carpus. The surgeon should not be concerned with radial height or inclination at this point; however, volar tilt should be established as best as possible. A rolled towel is placed dorsal to the metacarpals, holding the wrist in a flexed position as it is placed back onto the radiolucent hand table.

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