Open Reduction and Internal Fixation (ORIF) Distal Radial Fracture

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SAMPLE EXCERPT
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PRE-PROCEDURE
INDICATIONS
  • Type II distal radial shear fractures
    • Usually require open reduction and internal fixation
      • Barton's fractures are almost impossible to treat by closed means.
      • Buttress plate fixation of volar Barton's fractures is usually necessary.
  • Type III compression injuries
    • Require operative treatment if
      • Intraarticular damage is significant
      • Radial shortening is severe
    • Fixation with multiple Kirschner wires or plates is often necessary, and cancellous bone grafting is frequently required to fill impacted areas.
    • Often a combination of open and closed techniques is necessary to satisfactorily treat type III fractures.
  • Type IV avulsion fractures
    • Are usually associated with radiocarpal fracture-dislocations and are therefore unstable
    • Often the avulsed fracture fragments are so small that they can be repaired only with suture.
    • Secure reduction of the carpus to the distal radius can frequently be achieved only with Kirschner wires.

      Clinical Pearls: External fixation using the principle of ligamentotaxis is not appropriate in the treatment of radiocarpal fracture-dislocations because of the extensive ligament disruption.

  • Type V high-velocity fractures
    • Always unstable, frequently open, and difficult to treat
    • A combination of percutaneous pinning and external fixation is often necessary.
      • Many of these fractures are so severely comminuted that open reduction is impossible.
CONTRAINDICATIONS

Severe medical comorbidities that prevent surgery

EQUIPMENT
  • Hand tray and hand table
  • Small fragment and mini fragment set
  • Technique-specific tray, as required
ANATOMY
  • The distal radius and ulna may be divided into three distinct columns.
    • The lateral and medial columns correspond to the scaphoid facet and lunate facets, respectively, of the distal radius.
    • The medial column is further divided into dorsomedial and volar medial parts.
    • The ulnar column consists of the ulnar styloid and triangular fibrocartilage complex.
      • Tears of the triangular fibrocartilage occur when the medial column of the distal radius, ulnar styloid, or both are intact.
      • Distal radioulnar joint instability is associated with significant displacement of the ulnar styloid.

PROCEDURE
Sample excerpt does not include step-by-step text instructions for performing this procedure
The full content of this section includes:
  • Step-by-step text instructions for performing the procedure
  • Clinical pearls providing practical clinical tips from medical experts
  • Patient safety guidelines consistent with Joint Commission and OHSA standards
  • Links to medical evidence and related procedures

POST-PROCEDURE
TECHNIQUES
  • Post-Procedure: Distraction Plate Fixation
  • Post-Procedure: Volar Buttress Plate Fixation (Ellis)
  • Post-Procedure: Volar Plating of Intraarticular Compression Injuries (Medoff)

Post-Procedure: Distraction Plate Fixation

POST-PROCEDURE CARE
  • Immediately begin finger and other joint upper extremity exercises.
  • If a splint was applied, it should be removed at 3 weeks.
  • Percutaneous Kirschner wires should be removed at 6 weeks.
  • Activities of daily living are allowed, but lifting should be restricted to 5 lb.
  • Once union is achieved, remove the distraction plate and begin range-of-motion exercises.
COMPLICATIONS
  • Median nerve injury
  • Reflex sympathetic dystrophy
  • Malunion, nonunion
  • Tendon rupture
  • Infection
ANALYSIS OF RESULTS

Studies have demonstrated a high percentage of good to excellent outcomes for distraction plate fixation.

OUTCOMES AND EVIDENCE

Ruch et al reported good to excellent outcomes in 90% of 22 patients using this technique.

Procedure: Distraction Plate Fixation

Post-Procedure: Volar Buttress Plate Fixation (Ellis)

POST-PROCEDURE CARE
  • Immobilize the wrist and forearm with a plaster sugar tong splint for 2 weeks.
  • Next, use a removable ball-peen splint, permitting gentle active exercises two or three times a day for the next 2 weeks.
  • All immobilization is removed at 4 weeks and progressive motion continued until union is solid.
COMPLICATIONS
  • Median nerve injury
  • Reflex sympathetic dystrophy
  • Malunion, nonunion
  • Tendon rupture
  • Infection
ANALYSIS OF RESULTS

The use of buttress plating for the treatment of distal radius fractures have proven to yield excellent results when surgical intervention occurs early and care is used to obtain anatomic reduction of the fracture.

OUTCOMES AND EVIDENCE
  • Smith et al: 100% union rate with 71% excellent, 18% good, and 11% fair results.
  • Odumala et al: No difference in development of median nerve symptoms in patients treated with prophylactic carpal tunnel decompression compared with those without decompression.
Procedure: Volar Buttress Plate Fixation (Ellis)

Post-Procedure: Volar Plating of Intraarticular Compression Injuries (Medoff)

POST-PROCEDURE CARE
  • Keep the extremity elevated at all times until postoperative swelling subsides.
  • Beginning on the first postoperative day, remove the splint 2 to 3 times a day for range-of- motion exercises.
  • Allow clerical work at 2 weeks.
  • Resistive loading is allowed when signs of radiographic union appear.
COMPLICATIONS
  • Median nerve injury
  • Reflex sympathetic dystrophy
  • Malunion, nonunion
  • Tendon rupture
  • Infection
ANALYSIS OF RESULTS

Studies have demonstrated a high percentage of good to excellent outcomes for the Medoff system.

OUTCOMES AND EVIDENCE

Medoff reported 20 good to excellent results in 21 patients with intraarticular comminuted distal radial fractures treated with the TriMed Wrist Fixation System (TriMed, Valencia, Calif.).

Procedure: Volar Plating of Intraarticular Compression Injuries (Medoff)
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