import { OnePagerSummary, ContentSection, ExamWarning, InfoCardGrid, InfoCard, EvidenceCard, ComparisonTable, VivaScenario, MnemonicCard, ExamCheatSheet, Tab, Tabs } from '@/components/mdx' ### Why This Approach Dominates Distal Radius Surgery The volar approach to the distal radius has achieved near-universal adoption for ORIF of distal radius fractures, representing one of the most dramatic surgical paradigm shifts in modern orthopaedics: **The Revolution (1990s-2000s):** - **Pre-2000**: Dorsal plating standard (via dorsal approach) - high extensor tendon rupture rates (10-15%), prominent hardware, poor cosmesis - **2000-2005**: Volar locked plating introduced (Orbay, Jupiter) - fixed-angle screws prevent collapse, low-profile plates reduce tendon irritation - **2005-Present**: Volar approach becomes gold standard - 90% of distal radius ORIF now volar (Australian data mirrors global trends) **Three Reasons Volar Plating Won:** 1. **Biomechanical Superiority**: Fixed-angle (locked) screws resist dorsal collapse (most common deformity in Colles fractures) better than dorsal non-locked plates 2. **Soft Tissue Friendly**: Volar surface has pronator quadratus muscle coverage - acts as biological barrier between plate and flexor tendons (dorsal surface is subcutaneous - no muscle coverage) 3. **Early Mobilization**: Stable fixation allows immediate wrist ROM - reduces stiffness (critical in elderly patients prone to frozen wrist) **Australian Surgical Practice:** Distal radius fractures are the **most common fracture in adults over 50** (25% of all fractures in this age group - Australian injury surveillance data). The shift to volar plating has been near-complete in metropolitan centers (95% volar vs 5% dorsal for operative cases), with evidence supporting better functional outcomes and lower complication rates compared to historical dorsal approaches. ### Fracture Indications (Primary Use) **Absolute Indications for ORIF:** - **Displaced Intra-articular Fracture**: Articular step-off >2mm (post-reduction films) - **Unstable Extra-articular Fracture**: Dorsal comminution, dorsal tilt >20°, radial shortening >5mm, ulnar variance >3mm positive - **Open Fractures**: Gustilo I-II (volar ORIF + soft tissue coverage) - **Bilateral Fractures**: Functional independence requires bilateral surgery (patient cannot use crutches/walker) **Relative Indications:** - **Failed Closed Reduction**: Loss of reduction in cast at 7-10 days (acceptable parameters lost) - **Patient Factors**: High functional demands (professional/athletes), manual labourers (need strength restoration) - **Age and Activity**: Young patients (<65) with any displacement (higher functional demands than elderly) **Fracture Patterns Suited to Volar Approach:** 1. **Colles Fracture** (Dorsally Displaced Extra-articular) - Most common distal radius fracture (90%) - Dorsal tilt, radial shortening, impaction - Volar plate resists dorsal collapse (buttress effect) 2. **Smith's Fracture** (Volarly Displaced) - "Reverse Colles" - volar tilt, volar displacement - Volar plate directly buttresses volar fragment (ideal indication) 3. **Intra-articular Patterns:** - **Die-punch fragment**: Lunate facet impaction (reduces via volar, plate holds) - **Volar Barton**: Volar rim fracture with radiocarpal subluxation (direct fixation via volar) - **3-part/4-part**: Complex intra-articular (requires articular reduction via approach or arthroscopy-assisted) 4. **Chauffeur's Fracture** (Radial Styloid) - Avulsion fracture radial styloid (scapholunate ligament insertion) - Volar approach provides access to styloid for ORIF ### Non-Fracture Indications **Malunion Correction:** - Symptomatic distal radius malunion (loss of radial height, dorsal angulation causing DRUJ incongruity) - Approach allows osteotomy, reduction, plate fixation **Carpal Tunnel Release:** - Can combine CTR with fracture fixation (same skin incision, extended distally into palm) - Useful if acute carpal tunnel syndrome complicates fracture (10-15% of distal radius fractures) **Volar Plate Removal:** - Symptomatic hardware (flexor tendon irritation, prominent plate) - Same approach for explantation ### Contraindications **Absolute:** - **Active Infection**: Volar soft tissue infection, osteomyelitis (staged treatment required) - **Severe Open Fracture**: Gustilo III with volar contamination (consider external fixation, delayed ORIF) **Relative:** - **Dorsal Barton Fracture**: Dorsal rim fracture (may need dorsal plate for buttress) - **Highly Comminuted Volar Cortex**: No stable platform for plate (consider bridging external fixation) - **Severe Soft Tissue Injury**: Volar skin loss, crush injury (wound healing concerns) - **Patient Non-compliance**: Dementia, unable to follow postop precautions (consider percutaneous pinning or casting) ### Clinical Assessment **Mechanism of Injury (Informs Fracture Pattern):** - **Fall on outstretched hand (FOOSH)**: Low-energy Colles (elderly) vs high-energy comminuted (young) - **Dashboard injury**: High-energy axial load (expect intra-articular involvement, carpal injuries) - **Crush injury**: Open fracture risk, soft tissue damage (consider external fixation) **Physical Examination:** **Inspection:** - Deformity: "Dinner fork" (Colles - dorsal angulation) vs "Garden spade" (Smith - volar angulation) - Swelling: Severe swelling may delay surgery (compartment syndrome risk, skin blisters) - Skin integrity: Open wounds, blisters, abrasions (infection risk, surgical timing) **Palpation:** - Tenderness: Radiocarpal joint (intra-articular), DRUJ (associated injury), scaphoid (concomitant scaphoid fracture 5%) - Pulses: Radial artery (thrombosis rare but catastrophic - document preop) - Distal radioulnar joint (DRUJ): Painful DRUJ suggests triangular fibrocartilage complex (TFCC) injury or distal ulna fracture **Neurovascular Examination (MANDATORY):** - **Median nerve**: Thumb opposition (APB), sensation index finger (carpal tunnel syndrome in 10-15% acute fractures) - **Ulnar nerve**: Finger abduction (interossei), sensation small finger - **Radial nerve**: Wrist/finger extension (PIN), sensation first web space (superficial radial nerve) - **Vascular**: Radial pulse, ulnar pulse (Allen test if radial artery concern), capillary refill ### Imaging Essentials **Radiographs (PA, Lateral, Oblique):** **PA View Measurements:** - **Radial Height**: Normal 11-13mm (distance from radial styloid to articular surface of ulnar head) - Accept <5mm shortening in elderly, <2mm in young - **Radial Inclination**: Normal 22-23° (angle between articular surface and perpendicular to radial shaft) - Accept >15° in elderly, >20° in young - **Ulnar Variance**: Normal neutral to 2mm negative (ulna shorter than radius) - Positive variance >3mm associated with TFCC injury, DRUJ arthritis **Lateral View Measurements:** - **Volar Tilt**: Normal 10-12° volar (distal radius articular surface tilts volarly) - Colles fracture: Dorsal tilt (reverse of normal) - Smith fracture: Excessive volar tilt (>20°) - Accept neutral to 10° volar tilt in elderly, require anatomic in young - **Dorsal Comminution**: Predicts instability (requires fixation vs casting) **Oblique View:** - Radial styloid fracture (chauffeur's) - Volar/dorsal Barton fragments (rim fractures with carpal subluxation) **CT Scan (Intra-articular Fractures):** - **Articular Step-off**: Quantify gap/step (>2mm = surgical indication) - **Die-punch Fragment**: Lunate facet impaction (central articular depression) - **Fracture Comminution**: Plan fixation (may need dorsal plate if dorsal Barton, fragment-specific screws) - **DRUJ Assessment**: Distal ulna fracture, sigmoid notch fracture (associated DRUJ instability) **MRI (Rarely Indicated):** - TFCC injury suspected (painful DRUJ, ulnar-sided wrist pain persists post-healing) - Scapholunate ligament injury (widened scapholunate interval on PA X-ray - >3mm) ### Surgical Planning Decision Points **Fixation Strategy:** **Plate Positioning - The Watershed Line:** The "watershed line" is the critical anatomical boundary for volar plate positioning: - **Definition**: Proximal extent of volar distal radius where flexor tendons contact bone (approximately 2cm proximal to radiocarpal joint) - **Rule**: Plate MUST be distal to watershed line (flush with volar radius surface, not proud) - **Why**: Plates proximal to watershed = prominent = flexor tendon (especially FPL) irritation/rupture **Screw Length Planning:** - **Distal Screws**: Subchondral purchase (within 3mm of articular surface on lateral fluoro) - provides best fixation - **Length Calculation**: Lateral fluoroscopy measurement minus 2mm (accounts for articular cartilage thickness) - **Avoid**: Dorsal penetration (extensor tendon irritation), intra-articular penetration (arthritis) ### Essential Instrumentation **Standard Orthopaedic Set:** - Scalpel (15 blade - smaller incision, better control) - Self-retaining retractor (small Weitlaner) - Army-Navy retractors (superficial tissue) - Freer elevator (pronator quadratus elevation - subperiosteal) - Electrocautery (bipolar preferred - less collateral thermal injury) **Fracture-Specific Instruments:** - **Reduction Forceps**: Pointed reduction clamps (reduce fracture before plating) - **K-wires**: 1.2mm for provisional fixation (hold reduction during plating) - **Distractor**: External fixator or manual traction (restores radial length if impacted) - **Fluoroscopy**: C-arm (MANDATORY - intraop imaging for reduction, screw length, hardware position) **Volar Plate System:** - **Anatomic Volar Locked Plate**: Manufacturer-specific (DVR Biomet, Acu-Loc Acumed, VariAx Stryker) - Distal locking screws (fixed-angle or variable-angle) - 3.5mm diameter - Proximal cortical or locking screws - 3.5mm diameter - Plate benders (contour to volar radius if needed - minimal bending) - **Screwdriver**: Locking (dedicated for locked screws), standard (cortical screws) - **Drill**: 2.7mm drill bit (pilot hole for 3.5mm screws) - **Depth Gauge**: Measure screw length (critical - avoid dorsal penetration) **Fragment-Specific Fixation (If Needed):** - Small fragment screws (2.0mm, 2.4mm headless compression screws for styloid, lunate facet) - Additional mini-plates (radial styloid plate, lunate facet plate) ### Implant Selection **Volar Locked Plate Choice:** - **Standard Profile**: 2.4mm thick plates (most common - Acu-Loc, DVR) - **Ultra Low-Profile**: 1.8mm thick plates (higher flexor tendon irritation risk if prominent, but less bulky) - **Variable-Angle Screws**: Allow screw angulation ±15° (target specific fragments - die-punch, styloid) **Screw Selection:** - **Distal Screws**: Locking (provide angular stability - resist dorsal collapse) - **Proximal Screws**: Locking or cortical (cortical adequate if good bone quality, cheaper) - **Length**: Critical decision - measure EVERY screw intraoperatively (lateral fluoro) **Graft Options (If Needed):** - **Bone Void Filler**: Calcium phosphate cement (Norian, Callos) for metaphyseal defects (die-punch impaction) - **Autograft**: Distal radius cancellous bone (harvest from fracture fragments) or iliac crest (rare - major defects) - **Allograft**: Cancellous chips (metaphyseal void filling) ### Standard Positioning - Hand Table **Setup:** 1. **Patient Position**: Supine on OR table, operative arm abducted 90° on radiolucent hand table 2. **Hand Table**: Radiolucent (allows fluoroscopy - AP, lateral, oblique views) 3. **Arm Position**: Shoulder abducted 80-90°, elbow flexed 90°, forearm supinated (volar surface up) 4. **Tourniquet**: Upper arm pneumatic tourniquet (inflated to 250mmHg - exsanguinate with Esmarch first) **Advantages:** - **Surgeon Ergonomics**: Seated position, arm at comfortable working height (avoid back strain) - **Fluoroscopy Access**: C-arm easily positioned (perpendicular to forearm for lateral, parallel for AP) - **Assistant Position**: Across table (provides countertraction, handles reduction clamps) **Disadvantages:** - **Requires Hand Table**: Not all ORs equipped (can use standard table with arm board) - **Limited Extension**: Cannot extend incision above mid-forearm (hand table length limits) ### Alternative Positioning - Arm Board **Setup:** 1. Patient supine, arm on standard radiolucent arm board (attached to OR table side) 2. Position allows full forearm exposure (elbow to hand) 3. Less ideal for fluoroscopy (C-arm positioning more difficult) ### Tourniquet Considerations **Tourniquet Use (Standard Practice):** - **Advantages**: Bloodless field (visualization of median nerve, radial artery), faster surgery - **Technique**: - Upper arm pneumatic cuff - Exsanguinate with Esmarch bandage (elevate arm 1 minute, then wrap distal to proximal) - Inflate to 250mmHg (add 100mmHg to systolic BP) - Safe time limit: 2 hours (most distal radius ORIF <60 minutes) - **Release Before Closure**: Achieve haemostasis before tourniquet deflation (prevents postop haematoma) **No Tourniquet (Alternative):** - Used if tourniquet contraindicated (arterial disease, sickle cell, limb ischemia risk) - Requires meticulous haemostasis with bipolar cautery - Median nerve and radial artery more difficult to identify (not exsanguinated) ### Surface Landmarks **Palpable Structures (Mark Preoperatively):** 1. **Radial Styloid**: Most distal radial prominence (lateral wrist) - palpable 2. **FCR Tendon**: Palpate at wrist crease - most prominent flexor tendon on radial side (ask patient to flex wrist against resistance) 3. **Radial Artery Pulse**: Lateral to FCR tendon (palpate between FCR and brachioradialis) 4. **Distal Wrist Crease**: Approximate level of radiocarpal joint **Incision Planning:** - Start: 1cm proximal to distal wrist crease (avoid crease itself - hypertrophic scar) - Direction: Longitudinal along FCR tendon (radial border of volar forearm) - Length: 8-10cm (allows exposure from mid-pronator quadratus to proximal radius metaphysis) - Endpoint: Distal end at radial styloid level (can extend into palm if CTR needed) ### Anatomic Intervals and Structures **The FCR Interval:** - **Radial Border**: FCR tendon (flexor carpi radialis - inserts at base of 2nd metacarpal) - **Lateral Structure**: Radial artery (runs between FCR and brachioradialis in forearm) - **Medial Structure**: Median nerve (deep to flexor digitorum superficialis at wrist level) **Key Point**: This is NOT an internervous plane - it's a tendon-artery interval. The FCR is innervated by the median nerve, and the brachioradialis (lateral) is innervated by the radial nerve, but you're NOT dissecting between these muscles - you're working between the FCR tendon and the radial artery. ### Critical Neurovascular Anatomy **Palmar Cutaneous Branch of Median Nerve (PCB):** - **Course**: Arises from median nerve 5-7cm proximal to wrist crease, travels subcutaneously (superficial to flexor retinaculum) - **Position**: Crosses surgical field OBLIQUELY (radial to ulnar direction as it travels distally) - **Variability**: High (20-30% of patients have PCB crossing directly in surgical field) - **Innervation**: Sensory to thenar eminence skin (thumb base) - **Injury Consequences**: Painful neuroma (10-20% if divided), sensory loss thenar eminence, pillar pain (hyperesthesia) **Median Nerve (Main Trunk):** - **Position**: Medial (ulnar) to FCR tendon at wrist level (5-10mm medial) - **Course**: Deep to flexor digitorum superficialis (FDS), enters carpal tunnel at wrist - **At Risk**: If retraction too aggressive medially (traction injury), during pronator quadratus elevation if dissect too far ulnar - **Protection**: Gentle medial retraction, stay on radial side of pronator quadratus **Radial Artery:** - **Position**: Lateral (radial) to FCR tendon (between FCR and brachioradialis in forearm, between FCR and radial styloid at wrist) - **Course**: Runs on volar surface of pronator quadratus distally, winds around radial styloid into anatomic snuffbox - **At Risk**: During FCR sheath opening (may be adherent to radial border of sheath), fracture manipulation (spasm/thrombosis rare <1%) - **Palpate**: Throughout case (ensure pulse present - if lost, assess for kinking, spasm, thrombosis) **Anterior Interosseous Nerve (AIN):** - **Position**: Deep on interosseous membrane (between radius and ulna) - **Course**: Travels distally with anterior interosseous artery, innervates pronator quadratus (motor), distal radius periosteum (sensory) - **At Risk**: During pronator quadratus elevation (nerve on deep surface), fracture manipulation - **Function**: Motor to FPL, FDP to index, pronator quadratus (not testable intraop - patient asleep) ### Flexor Tendon Anatomy **Flexor Pollicis Longus (FPL):** - **Position**: Most radial flexor tendon (crosses distal radius at watershed line level) - **At Risk**: Screw penetration dorsal cortex (screw tips contact FPL), plate prominence proximal to watershed (plate-tendon friction = rupture) - **Protection**: Measure screw length accurately (lateral fluoro - subtract 2mm), ensure plate distal to watershed **Flexor Carpi Radialis (FCR):** - **Sheath**: Tendon runs in fibro-osseous tunnel (FCR groove on volar radius - trapezium distally) - **Surgical Use**: FCR sheath is opened (tendon retracted ulnar) to access radius - **Repair**: FCR sheath usually NOT repaired (no functional consequence) ### Pronator Quadratus Muscle **Anatomy:** - **Origin**: Distal ulna volar surface (distal 25% of ulna) - **Insertion**: Distal radius volar surface (distal 25% of radius) - **Fibers**: Horizontal (deepest forearm muscle - directly overlies volar distal radius) - **Innervation**: Anterior interosseous nerve (AIN) - branch of median nerve **Surgical Importance:** 1. **Covers Volar Radius**: Must elevate pronator quadratus to expose fracture/distal radius 2. **Plate Coverage**: Repair of pronator quadratus over plate provides biological barrier (reduces flexor tendon irritation 50%) 3. **Blood Supply to Distal Radius**: Pronator quadratus has rich vascular supply (healing benefit if preserved) **Elevation Technique:** - **L-shaped Flap**: Incise pronator along radial insertion (vertical limb), extend ulnar along distal border (horizontal limb) - **Subperiosteal**: Elevate muscle off radius as flap (preserves muscle, allows anatomic repair) - **Preserve Ulnar Insertion**: Keeps muscle viable (blood supply from ulnar side) ### Step 1: Skin Incision and Superficial Dissection **Incision:** - **Start Point**: 8-10cm proximal to wrist crease (mid-volar forearm) - **Direction**: Longitudinal along FCR tendon (palpate tendon, mark with skin marker) - **Length**: 8-10cm (allows exposure of distal radius from metaphysis to radiocarpal joint) - **End Point**: Distal end at radial styloid level (or extend into palm if CTR needed) **Avoid Wrist Crease:** Do NOT make incision directly in wrist crease (hypertrophic scarring, wound breakdown risk). Stay 1-2cm proximal to crease. **Skin Dissection:** - 15 blade scalpel, incise dermis - Deepen through subcutaneous fat (3-5mm depth) - Identify superficial veins (ligate or cauterize with bipolar) **Identify Palmar Cutaneous Branch (CRITICAL STEP):** During subcutaneous dissection, actively LOOK for palmar cutaneous nerve: - Small white nerve (1-2mm diameter) - Crosses field obliquely (radial to ulnar direction distally) - Runs in subcutaneous tissue (superficial to deep fascia) - **If Identified**: Place vessel loop around nerve, gentle retraction (protect throughout case) - **If Not Seen**: Assume it's there - gentle handling of subcutaneous tissue, minimize traction ### Step 2: Identify and Open FCR Tendon Sheath **Palpate FCR Tendon:** - Most prominent radial-sided flexor tendon at wrist - Firm white cord (visible through deep fascia once subcutaneous tissue divided) - Distal to proximal: Tendon enters FCR groove (trapezium), then runs in sheath on radius **Palpate Radial Artery:** - Lateral to FCR (between FCR and brachioradialis distally) - Pulsatile (if tourniquet not inflated) or cord-like (if exsanguinated) - Mark position mentally (MUST protect throughout case) **Open FCR Sheath:** 1. Identify sheath (thin white fascial layer overlying FCR tendon) 2. Incise sheath longitudinally (15 blade - parallel to tendon fibers) 3. Open sheath from wrist crease (distal) to 8cm proximally 4. Reflect sheath edges (FCR tendon now visible in base of wound) **Retract FCR Tendon:** - Place small Army-Navy or Senn retractor ULNAR to FCR (retracts FCR medially) - Radial artery retracts LATERALLY with brachioradialis (stays protected lateral) - You've now created the interval: Radial artery (lateral), FCR tendon (medial/ulnar) ### Step 3: Expose Pronator Quadratus **Identify Pronator Quadratus:** - Deepest structure in wound (after FCR retracted ulnar, radial artery retracted radial) - Horizontal muscle fibers (perpendicular to forearm long axis) - Covers entire volar distal radius surface **Palpate Fracture Through Pronator:** - Dorsal displacement palpable (Colles - dorsal step in bone under muscle) - Radial shortening palpable (fracture fragments may be impacted) - Swelling/haematoma within pronator muscle (fracture haematoma) ### Step 4: Elevate Pronator Quadratus (L-Shaped Flap) **Incision Design:** 1. **Vertical Limb**: Incise pronator along radial insertion (where muscle inserts on radius radial border) - Start at radial styloid (distal), extend 6-8cm proximally - Stay on muscle insertion (elevate muscle off bone subperiosteally) 2. **Horizontal Limb**: At proximal extent of vertical incision, turn 90° ulnar - Incise along distal border of pronator (just proximal to radiocarpal joint) - Extend ulnar 2-3cm (creates L-shaped flap) **Elevate Flap:** - Freer elevator (or periosteal elevator) - subperiosteal dissection - Elevate pronator quadratus OFF radius (from radial to ulnar direction) - Muscle elevates as flap (ulnar insertion intact - preserves blood supply) - Reflect flap ulnar (exposes entire volar distal radius surface) **What You See:** - Volar distal radius cortex (bone surface) - Fracture line(s) visible - Haematoma (evacuate with suction) - Assess fracture pattern (extra-articular vs intra-articular, comminution) ### Step 5: Fracture Reduction **Reduction Maneuvers:** **Extra-articular Fractures (Colles):** 1. **Restore Radial Length**: Apply longitudinal traction (assistant pulls on thumb, surgeon grasps proximal fragment) - Disimpact fracture (dorsal cortex usually impacted) - Consider external distractor if severe impaction (rare - manual traction usually sufficient) 2. **Correct Dorsal Tilt**: Volar translation of distal fragment (push volar from dorsal) - Dorsally displaced fragment needs volar translation + flexion force - Palpate dorsal cortex (ensure reduced - should feel flush) 3. **Provisional Fixation**: K-wires (1.2mm) from radial styloid into proximal fragment - 2-3 K-wires hold reduction while applying plate - Check fluoroscopy (AP and lateral - confirm acceptable reduction) **Intra-articular Fractures:** 1. **Identify Articular Fragments**: Die-punch (lunate facet impaction), radial styloid, volar/dorsal rim 2. **Reduce Articular Surface**: - Elevate die-punch fragment (Freer elevator through fracture site) - Reduce styloid fragment (clamp to shaft with pointed reduction forceps) - Bone graft/void filler if metaphyseal defect (die-punch creates void when elevated) 3. **Provisional Fixation**: K-wires hold fragments reduced 4. **Fluoroscopy**: Confirm articular step <2mm (AP, lateral, oblique views) **Reduction Goals (Fluoroscopy Confirmation):** - **AP View**: Radial height restored (11-13mm), radial inclination >20°, no articular step - **Lateral View**: Volar tilt 0-10° (neutral to slight volar), no dorsal angulation, articular surface congruent ### Step 6: Plate Application **Plate Selection:** - Anatomic volar locked plate (sized to distal radius - small, standard, large based on patient size) - Most adults: Standard plate (covers volar radius without overhang) **Plate Positioning (CRITICAL):** **Distal-Proximal Position:** - Plate should sit JUST PROXIMAL to watershed line (2cm proximal to radiocarpal joint) - Distal edge of plate at pronator quadratus distal insertion level - Too distal: Plate extends onto volar rim (intra-articular, blocks wrist flexion) - Too proximal: Plate proud of watershed line (flexor tendon irritation) **Radial-Ulnar Position:** - Plate centered on volar radius (avoid radial or ulnar overhang) - Radial edge of plate at junction of radial styloid and volar shaft **Plate Contouring:** - Minimal bending (plates are pre-contoured to volar radius anatomy) - If needed: Gentle bending with plate benders (avoid sharp angles - stress risers) **Provisional Plate Fixation:** 1. Place plate on volar radius (position as above) 2. Insert 1-2 proximal NON-locking screws (cortical screws) - do NOT lock yet - Screws in oblong holes (allow plate to slide distally if needed) 3. Fluoroscopy (AP and lateral): Confirm plate position, check distal screw trajectories **Adjust Plate:** - If distal screws will penetrate dorsal cortex OR enter radiocarpal joint: Reposition plate (usually move proximal 2-3mm) ### Step 7: Distal Screw Insertion (Most Critical Step) **Distal Screw Principles:** - **Goal**: Subchondral purchase (screws within 3mm of articular surface - provides best fixation) - **Fixed-Angle**: Locking screws (prevent toggling, resist dorsal collapse) - **Length**: CRITICAL - must check EACH screw intraoperatively **Distal Screw Insertion Technique:** 1. **Drill Distal Holes**: 2.7mm drill bit through locking holes (drill guide ensures correct angle) - Lateral fluoroscopy: Confirm drill bit trajectory (parallel to articular surface, subchondral depth) - Drill until dorsal cortex (feel breakthrough, watch fluoro) 2. **Measure Screw Length**: - Depth gauge through drill hole (measures to dorsal cortex) - **SUBTRACT 2mm** from measurement (accounts for articular cartilage thickness - prevents intra-articular penetration) - Example: Depth gauge reads 18mm → Use 16mm screw 3. **Insert Locking Screws**: - Self-tapping locking screws (or tap first if non-self-tapping) - Insert 3-4 distal screws (depends on plate - usually 2 rows, 4-6 screws total) - Screw heads lock into plate (fixed angle - cannot toggle) 4. **Check EVERY Screw (Fluoroscopy)**: - **Lateral View**: Screws should end 2-3mm from dorsal cortex (MUST NOT penetrate dorsal cortex - extensor tendon irritation) - **AP View**: Screws within bone (not exiting radially or ulnarly) - **If Screw Long**: Remove, measure again, insert shorter screw ### Step 8: Proximal Screw Insertion **Proximal Fixation:** - **Goal**: Secure plate to radial shaft (prevents toggling, transfers load) - **Screw Type**: Locking or non-locking (cortical screws adequate if good bone quality) **Technique:** 1. Drill proximal holes (2.7mm drill bit) 2. Measure screw length (depth gauge - bicortical purchase ideal) 3. Insert 3-4 proximal screws (locking or cortical) 4. Tighten proximal screws (final plate position fixed) **Remove K-wires:** - Provisional K-wires removed (plate now provides definitive fixation) ### Step 9: Final Fluoroscopy Check **Systematic Fluoroscopy Protocol:** **AP View:** - [ ] Radial height restored (11-13mm normal) - [ ] Radial inclination >20° - [ ] No articular step-off (gap <2mm) - [ ] Screws within bone (no radial/ulnar overhang) - [ ] Ulnar variance neutral to 2mm negative **Lateral View:** - [ ] Volar tilt 0-10° (neutral to slight volar) - [ ] NO screw penetration dorsal cortex (screws 2-3mm from dorsal surface) - [ ] Plate proximal to radiocarpal joint (not blocking wrist flexion) - [ ] Articular congruity maintained **Oblique View:** - [ ] Radial styloid fragment reduced (if fractured) - [ ] Screw position acceptable (no joint penetration) **Range of Motion:** - Release tourniquet (assess reperfusion) - Passive wrist flexion/extension (ensure no block - plate not impinging) - Finger flexion/extension (ensure no tendon injury - FPL, FDP move freely) ### Step 10: Closure and Pronator Quadratus Repair **Pronator Quadratus Repair (CRITICAL for Outcomes):** **Why Repair Pronator?** - Creates biological barrier between plate and flexor tendons (reduces irritation 50%) - Provides vascular supply to distal radius (enhances healing) - Evidence: Patients with pronator repair have lower flexor tendon complication rates **Repair Technique:** **Option 1: Side-to-Side Repair (Preferred)** 1. Pronator quadratus flap reflected ulnar (radial insertion detached, ulnar insertion intact) 2. Re-approximate radial insertion to radius periosteum 3. 2-0 or 3-0 Vicryl sutures (mattress or simple interrupted) 4. 4-6 sutures along radial border (reattach muscle to insertion site) **Option 2: Transosseous Repair** 1. Drill small holes (2mm) in distal radius (lateral edge) 2. Pass sutures through bone holes, then through pronator muscle edge 3. Tie sutures (muscle apposed to bone) **If Pronator Cannot Reach:** - Severe comminution or tissue loss may prevent tension-free repair - Accept partial coverage (better than no coverage) - Consider brachioradialis turndown flap (advanced technique - rarely needed) **Fascial Closure:** - FCR sheath: Usually not repaired (no functional benefit) - Deep fascia (over pronator): 3-0 Vicryl interrupted (loose approximation) **Subcutaneous Closure:** - 3-0 Vicryl interrupted sutures (invert skin edges) - Ensure haemostasis (meticulous - wrist haematomas are common) **Skin Closure:** - 4-0 Monocryl subcuticular running suture (excellent cosmesis) - Dermabond or Steri-Strips (skin adhesive) **Dressing:** - Sterile gauze, cotton padding (circumferential but not compressive) - Volar splint (wrist neutral, forearm neutral rotation, fingers free to PIP joints) - Elevate hand postop (reduce swelling) ### Pre-Closure Verification **Fluoroscopy Final Check:** - [ ] AP: Radial height, inclination, no articular step, screws within bone - [ ] Lateral: Volar tilt 0-10°, NO dorsal screw penetration, plate position acceptable - [ ] Oblique: Fragment reduction adequate **Hardware Position:** - [ ] Plate distal to watershed line (will not irritate FPL) - [ ] All screws measured and checked (no dorsal penetration) - [ ] No screws intra-articular (lateral view confirms) **Haemostasis:** - [ ] Tourniquet deflated, bleeding controlled (cauterize vessels) - [ ] Radial artery pulse present (confirm perfusion) - [ ] No active bleeding from fracture site or soft tissue **Range of Motion:** - [ ] Passive wrist flexion/extension (no block from hardware) - [ ] Finger flexion/extension (FPL, FDP intact - no resistance) ### Layer-by-Layer Closure **Deep Layers:** 1. **Pronator Quadratus Repair**: 2-0 Vicryl × 4-6 sutures (side-to-side to radial periosteum) 2. **Deep Fascia**: 3-0 Vicryl × 3-4 interrupted (loose approximation over pronator) **Superficial Layers:** 3. **Subcutaneous**: 3-0 Vicryl × 6-8 interrupted (invert edges, meticulous haemostasis) 4. **Skin**: 4-0 Monocryl subcuticular running, Dermabond **Splint Application:** - Volar plaster splint (forearm-based, wrist neutral) - Fingers free to PIP joints (allows digit ROM - prevents stiffness) - Thumb IP joint free (allows thumb motion) - Splint extends to proximal palmar crease (allows full finger flexion) ### Intraoperative Complications **Palmar Cutaneous Nerve Injury (20-30% if not protected)** - **Mechanism**: Not identified during subcutaneous dissection, divided or stretched - **Presentation**: Immediate (cannot test intraop - patient asleep), postop painful thenar eminence - **Management**: - If recognized intraop (nerve cut): Primary repair (microsurgical - 8-0 nylon, nerve ends approximated) - If recognized postop: Observation 3-6 months (many improve), if persistent pain = neuroma excision + nerve burial - **Prevention**: Active search during subcutaneous dissection, vessel loop protection if identified **Radial Artery Injury (<1%)** - **Mechanism**: Laceration during FCR sheath opening (artery adherent to sheath), fracture manipulation (spasm) - **Presentation**: Loss of radial pulse, bleeding (if laceration) - **Management**: - Spasm: Warm saline, topical papaverine (usually resolves) - Laceration: Vascular repair (primary vs vein graft) - consult vascular if available - Ligation: Acceptable IF ulnar artery intact (check Allen test preop - documented), but preferably repair - **Prevention**: Identify radial artery before FCR sheath opening, palpate throughout case **Median Nerve Injury (<1%)** - **Mechanism**: Traction (aggressive medial retraction), direct trauma (dissection too far ulnar) - **Presentation**: Postop thenar weakness (APB), numbness median distribution - **Management**: Usually neuropraxia (observation, recovery 3-6 months), EMG at 6 weeks if no improvement - **Prevention**: Gentle medial retraction, stay on radial side of pronator quadratus **Flexor Pollicis Longus Tendon Injury** - **Mechanism**: Screw dorsal penetration (drill bit or screw perforates dorsal cortex, enters FPL) - **Presentation**: Cannot test intraop, postop weak/absent thumb IP flexion - **Management**: Revision surgery (remove offending screw, repair tendon if lacerated) - **Prevention**: Lateral fluoroscopy check of EVERY screw before proceeding **Loss of Reduction During Fixation** - **Mechanism**: Provisional K-wires lose purchase, fracture collapses during plating - **Presentation**: Fluoroscopy shows dorsal tilt recurrence or articular step - **Management**: Remove plate, re-reduce fracture, consider bone graft (if metaphyseal void), re-plate - **Prevention**: Adequate provisional fixation (2-3 K-wires), check reduction before drilling distal holes ### Early Postoperative Complications (0-6 weeks) **Carpal Tunnel Syndrome (10-15% transient)** - **Mechanism**: Median nerve compression (postop swelling, haematoma, fracture displacement pre-reduction) - **Presentation**: Numbness median distribution (thumb, index, middle fingers), weak thumb opposition - **Natural History**: Most resolve with swelling reduction (2-6 weeks), elevation, splint removal - **Management**: - Transient (improving): Observation, elevate hand, remove splint at 2 weeks - Persistent (>6 weeks) or severe: Carpal tunnel release (decompress median nerve) - **Prevention**: Adequate fracture reduction (relieves median nerve pressure), elevate hand postop **Infection (1-2%)** - **Presentation**: Wound erythema, drainage, pain, fevers (usually 7-14 days postop) - **Organisms**: Staph aureus (80%), Strep species - **Diagnosis**: Wound culture, blood cultures if systemic signs, CRP/ESR - **Management**: - Superficial (skin/subcutaneous): Oral antibiotics (flucloxacillin 500mg QID × 7 days per eTG) - Deep (plate contaminated): Surgical debridement, plate retention if stable + IV antibiotics (flucloxacillin 2g IV Q6h × 2 weeks per eTG) - Severe (osteomyelitis, loose plate): Explant plate, external fixation, delayed re-fixation - **Prevention**: Periop antibiotics (cephazolin 2g IV at induction per eTG), meticulous haemostasis, gentle tissue handling **Compartment Syndrome (Rare <1%)** - **Mechanism**: Volar forearm compartment pressure (haematoma, fracture displacement, tight splint/cast) - **Presentation**: Pain out of proportion (especially with passive finger extension), tense forearm, paresthesias - **Diagnosis**: Clinical (high suspicion), compartment pressure measurement if uncertain (>30mmHg = compartment syndrome) - **Management**: EMERGENCY fasciotomy (release volar and dorsal forearm compartments) - **Prevention**: Elevate hand postop, loose splint (not circumferential cast immediately postop), educate patient (return if severe pain) ### Late Postoperative Complications (>6 weeks) **Flexor Tendon Irritation/Rupture (2-5%)** - **Mechanism**: Plate prominence (proximal to watershed line), screw dorsal penetration (FPL contact) - **Presentation**: - Irritation: Painful wrist flexion, triggering sensation (FPL catching on plate) - Rupture: Sudden loss of thumb IP flexion (FPL rupture - usually 3-12 months postop) - **Diagnosis**: Clinical (inability to flex thumb IP joint), ultrasound (tendon discontinuity) - **Management**: - Irritation: Plate removal (if >6 months postfracture - bone healed) - Rupture: Tendon reconstruction (FPL tendon transfer - use palmaris longus graft, FDS ring finger transfer) - **Prevention**: Plate distal to watershed line, pronator quadratus repair, screw length checks **Malunion (5-10%)** - **Mechanism**: Loss of reduction (inadequate fixation, osteoporotic bone), non-compliance (early splint removal) - **Presentation**: Dorsal angulation (Colles deformity recurrence), radial shortening, ulnar-sided wrist pain (DRUJ incongruity) - **Diagnosis**: X-ray (lateral shows dorsal tilt, AP shows radial shortening, ulnar variance) - **Management**: - Symptomatic + <6 months: Corrective osteotomy (re-cut, re-reduce, re-plate ± bone graft) - Asymptomatic: Observation (many elderly patients tolerate mild malunion) - **Prevention**: Adequate fixation (locked distal screws, bone graft if metaphyseal void), splint compliance 6 weeks **Stiffness (10-20%)** - **Presentation**: Limited wrist ROM (especially extension - normal 60-70°, stiffness may be 20-30°) - **Risk Factors**: Prolonged immobilization (>6 weeks), intra-articular fractures, elderly patients - **Prevention**: Early ROM exercises (begin 2 weeks postop - gentle PROM, progress to AROM at 6 weeks) - **Management**: - <6 months: Intensive physiotherapy (3× per week, static progressive splinting) - >6 months: Manipulation under anaesthesia (rarely needed for distal radius - arthrofibrosis uncommon) **Complex Regional Pain Syndrome (CRPS) (5-10%)** - **Presentation**: Severe pain, swelling, skin color changes (red/blue), temperature changes (hot/cold), hypersensitivity - **Diagnosis**: Clinical (Budapest criteria - pain disproportionate to injury, vasomotor/sudomotor/motor changes) - **Management**: - Early mobilization (CRITICAL - prevents CRPS progression) - PT (desensitization, mirror therapy, graded motor imagery) - Medications (gabapentin, amitriptyline for neuropathic pain) - Stellate ganglion block (if refractory - anesthesia pain clinic) - **Prevention**: Adequate analgesia, early mobilization, avoid prolonged immobilization ### Immediate Postoperative Care (Day 0-1) **Recovery Room:** - Neurovascular check (median nerve function, radial pulse - document) - Pain control: Regional block (brachial plexus at axilla or forearm level), oral opioids (oxycodone 5mg PRN) - X-ray (AP and lateral wrist - confirm hardware position unchanged, no intraop loss of reduction) **Ward Care:** - Hand elevation (above heart level - reduces swelling, prevents haematoma) - Cryotherapy (ice packs 20 min Q2h - reduces swelling, improves pain) - Digit ROM (immediate finger/thumb flexion-extension - prevents stiffness, CRPS) **Discharge Criteria (Same Day or Day 1):** - Pain controlled (NRS <4/10 on oral meds) - Neurovascularly intact (median nerve, radial pulse documented) - Safe mobilization (sling not required - hand in splint, patient independent) - Understands splint care (keep dry, elevate, finger ROM exercises) ### Outpatient Follow-up Protocol **Week 2:** - **Wound Check**: Remove dressing, assess for infection (erythema, drainage) - **Suture Removal**: If non-absorbable (most use absorbable - no removal needed) - **Splint**: Continue volar splint (wrist neutral, fingers free) - **X-ray**: AP and lateral wrist (assess hardware position, early healing) - **Physiotherapy**: Finger/thumb ROM (full flexion-extension), gentle wrist PROM (PT-assisted if stiff) **Week 6:** - **X-ray**: AP, lateral, oblique (assess fracture healing - bridging callus expected) - **Clinical Exam**: ROM (PROM vs AROM), tenderness, grip strength - **Splint Removal**: Discontinue splint (fracture stable with plate, bone healing progressing) - **Physiotherapy Progression**: - Active wrist ROM (AROM - flexion, extension, radial/ulnar deviation) - Light resistance (Theraband, putty exercises) - Avoid heavy lifting >2kg (bone still healing) **Week 12:** - **X-ray**: Confirm union (cortical bridging on 3/4 cortices) - **ROM Goals**: Flexion 60-70° (80% contralateral), extension 50-60° (80% contralateral) - **Strength Testing**: Grip strength 50-70% of contralateral (Jamar dynamometer) - **Return to Activity**: Unrestricted ADLs, light work (no heavy labour yet) **Month 6:** - **Final X-ray**: Confirm mature union, assess for hardware complications (loosening rare) - **ROM**: Should be 80-90% of contralateral wrist (near-normal function) - **Return to Full Activity**: Manual labour, contact sports OK (fracture healed, plate provides long-term support) - **Hardware Removal**: Consider if symptomatic (flexor tendon irritation, plate prominence) - remove >12 months postop (bone remodeling complete) ### Physiotherapy Protocol **Phase 1 (Weeks 0-2): Protection + Digit Mobilization** - **Goals**: Prevent finger stiffness, reduce swelling - **Exercises**: - Finger flexion-extension (make full fist, then fully extend - 10 reps Q2h) - Thumb opposition (touch thumb to each fingertip - prevents CMC stiffness) - Elevation (hand above heart - gravity drainage of edema) - **Restrictions**: Wrist immobilized in splint (no wrist ROM), no lifting **Phase 2 (Weeks 2-6): Gentle Wrist PROM** - **Goals**: Prevent wrist stiffness, maintain fracture reduction - **Exercises**: - Passive wrist flexion-extension (PT-assisted or opposite hand - gentle ROM) - Forearm rotation (pronation-supination - elbow at side, 90° flexed) - Edema control (retrograde massage, compression glove if persistent swelling) - **Restrictions**: NO active wrist ROM (bone healing 3-6 weeks - avoid loads on fracture), NO lifting **Phase 3 (Weeks 6-12): Active ROM + Light Strengthening** - **Goals**: Restore active wrist ROM, begin strengthening - **Exercises**: - Active wrist flexion-extension (no weight - gravity resistance only) - Wrist radial-ulnar deviation (active ROM) - Theraband resistance (light - wrist flexion/extension against band) - Grip strengthening (putty, sponge squeeze - light resistance) - **Restrictions**: Avoid heavy lifting >2kg **Phase 4 (Months 3-6): Return to Function** - **Goals**: Full ROM, near-normal strength - **Exercises**: Progressive resistance (weights 2-5kg), functional activities (lifting, carrying) - **Return to Work**: Sedentary 6 weeks, light duty 3 months, heavy labour 6 months ### Australian-Specific Postoperative Considerations **Medicare and Physiotherapy:** Distal radius fractures qualify for CDM (Chronic Disease Management) plan - 5 subsidized PT visits. GP referral required. For working-age patients, workers compensation (if work-related injury) covers unlimited PT (better outcomes due to therapy compliance). **Return to Work:** - **Sedentary**: 6-8 weeks (office work, keyboard use) - **Light Manual**: 3 months (occasional lifting <5kg) - **Heavy Manual**: 6 months (repetitive lifting, manual labour) **Driving:** - Right wrist fracture: 6 weeks (splint prevents safe steering control) - Left wrist fracture: 2-4 weeks (can drive automatic with right hand earlier) - Inform patient preoperatively (arrange transport for first 6 weeks) **Medicolegal Considerations:** Document median nerve function preoperatively and postoperatively. Acute carpal tunnel syndrome is common (10-15%) - if present preop, document clearly. If develops postop, distinguish from surgical injury vs fracture-related compression. 60 years) with displaced distal radius fractures", "Volar locked plating vs closed reduction + casting", "At 12 months: Volar plating superior ROM (flexion-extension 134° vs 117°, p=0.001)", "DASH scores better with plating (10 vs 18, p=0.002)", "Complication rates similar (12% plating vs 15% casting)" ]} clinicalImplication="Establishes volar locked plating as superior to casting for displaced distal radius fractures in elderly patients - better functional outcomes (ROM, DASH) without increased complications. This RCT supports operative management even in low-demand elderly (contrary to older dogma favoring casting)." /> 10mm, tilt 5-10° volar, step <1mm); Elderly (>65) = acceptable (height >8mm, tilt neutral to 10° volar)" ] }, { title: "Intraop Fluoroscopy Checklist", content: [ "AP view: Radial height 11-13mm, radial inclination >20°, ulnar variance neutral to 2mm negative, articular step <2mm", "Lateral view: Volar tilt 0-10°, NO screw dorsal penetration (2-3mm from cortex), plate distal to watershed, articular congruity", "Oblique view: Radial styloid reduced (if fractured), screws within bone (not exiting radially)", "EVERY screw: Check lateral fluoro BEFORE next screw (dorsal penetration = EPL/FPL rupture risk)" ] }, { title: "Complications - Prevention", content: [ "Palmar cutaneous neuroma (20-30%): Identify and protect nerve during subcutaneous dissection (vessel loop if seen)", "FPL rupture (2-5%): Plate distal to watershed + pronator repair + screw length checks (no dorsal penetration)", "EPL rupture (4%): Screw length checks (Lister's tubercle level most at risk)", "Median nerve injury (<1%): Gentle medial retraction, stay radial side of pronator", "Loss of reduction (5-10%): Adequate provisional fixation (K-wires), locked distal screws, bone graft if metaphyseal void" ] }, { title: "Evidence You Must Know", content: [ "Arora 2011 JBJS RCT: Volar plating superior to casting in elderly (better ROM 134° vs 117°, DASH 10 vs 18)", "Soong 2011 JBJS: Watershed line classification - Grade 2 (proximal to watershed) = 5× FPL rupture risk", "Hershman 2013 JHS: Pronator repair reduces tendon complications (2% vs 11% without repair)", "Auerbach 2009 JHS: Palmar cutaneous nerve crosses field in 68% (high injury risk if not identified)", "Rozental 2006 meta-analysis: Volar plating lower tendon complications vs dorsal (2% vs 15%)" ] }, { title: "Viva Traps", content: [ "TRAP: 'Internervous plane' - WRONG, volar approach is INTRAMUSCULAR (through pronator quadratus), FCR interval is tendon-artery (not nerve)", "TRAP: 'Median nerve is main risk' - INCOMPLETE, palmar cutaneous branch is HIGHER risk (20-30% vs <1% main nerve)", "TRAP: 'Depth gauge reading = screw length' - WRONG, must SUBTRACT 2mm for cartilage thickness", "TRAP: 'Pronator repair optional' - WRONG, evidence shows 50% reduction in complications when repaired (mandatory technique)", "TRAP: 'All distal radius fractures need surgery' - WRONG, only if displaced >5mm shortening, >10° dorsal tilt, >2mm articular step, or unstable" ] }, { title: "Australian Context", content: [ "Most common fracture in adults >50 (25% of all fractures in this age group - Australian injury surveillance)", "Volar plating 90-95% of operative distal radius fractures (paradigm shift from dorsal approach 2000-2010)", "Medicare: CDM plan for PT (5 subsidized visits), workers comp unlimited PT if work-related", "Return to work: Sedentary 6-8 weeks, light manual 3 months, heavy manual 6 months", "Driving restriction: Right wrist 6 weeks (splint prevents safe steering), left wrist 2-4 weeks (can drive automatic earlier)" ] } ]} />

Volar Approach to Distal Radius

Volar Approach to Distal Radius