Operative Technique in Plastic Surgery – Kevin C.Chung

TECH FIG 5 • A. The proximal capitate is resected
flush with the base of the hamate. B. The distally
based dorsal capsular flap is sutured around the distal
carpal bones to the volar capsule.
■ In the traditional Salomon-Eaton procedure, the proximal capitate is then
resected with a sagittal saw or osteotome to the level of the hamate (TECH
FIG 5A). However, resection of the proximal capitate is not required for flap
interposition and may result in deleterious injury to the remaining capitate
and/or proximal hamate. The authors recommend leaving the capitate as is
prior to flap interposition.
■ The dorsal L-shaped capsulotomy is converted into a distally based
rectangular flap by creating a longitudinal incision in the capsule on the ulnar
aspect of the capitate.
■ The dorsal flap is then sutured around the proximal capitate to the volar
capsule with 4-0 nonabsorbable suture (TECH FIG 5B).
■ A 0.062-in. K-wire is then inserted in a retrograde fashion from the capitate
to the radius to secure it in the lunate fossa.
■ As there is no dorsal capsule to close with this technique, closure begins
with repair of the extensor retinaculum and proceeds in the standard fashion.

■ Proximal Row Carpectomy with Osteochondral
Grafting
■ This modification of PRC is indicated for resurfacing limited arthritis (less
than 10 mm) of the proximal capitate.13 The procedure uses an osteochondral
graft harvested from one of the removed carpal bones that is placed into the
proximal capitate articular surface.
■ The procedure begins as in the standard PRC.
■ Once the capitate is inspected and found to have a small area of cartilage
loss (less than 10 mm), osteochondral grafting can be performed.
■ The proximal row is removed as in the standard PRC; however, at least one
of the bones must be removed en bloc to harvest the osteochondral graft.
■ Once the proximal row is removed, the size of the cartilage defect in the
capitate is determined and resected with a reamer for a depth of 10 mm.
■ A harvesting dowel of matching diameter is then used to harvest a full-
thickness osteochondral graft from one of the removed bones in an area of
pristine cartilage, usually on the lunate or triquetrum.
■ The graft is cut down to 10 mm in length and then gently impacted into the
defect in the proximal capitate until the cartilage surface is flush.
■ Closure proceeds in the same fashion for a standard PRC.
PEARLS AND PITFALLS
Patient
selection
■ PRC has the longest durability in older patients (older than 40 years)
with low physical demands.
Planning
■ Patients with evidence of lunocapitate arthritis on radiographs should
not be offered PRC.
■ Designing the L-shaped capsulotomy in all patients reserves the dorsal
capsule interposition flap as a bail-out in cases with mild arthritis
encountered intraoperatively.
Technique
■ Blunt dissection around the scaphoid is crucial to preserve the RSC
ligament.
■ Failure to preserve this ligament may lead to poor alignment of the

capitate and lunate fossa and early failure of the procedure.
Technique
■ Avoid damage to the proximal capitate and lunate fossa of the radius
during removal of the proximal row.
Therapy
■ Early motion postoperatively allows for quicker return to of motion
without any adverse outcomes.
POSTOPERATIVE CARE
■ Patients are seen in the office 2 weeks after surgery and the splint and sutures
removed.
■ Standard radiographs of the wrist are obtained to confirm appropriate
alignment of the radiocapitate articulation (FIG 2).
■ Patients in whom the RSC was protected and have maintained alignment can
begin an early protected range of motion protocol.14,15
■ Strengthening of the wrist is reserved until 6 to 8 weeks postoperatively.
OUTCOMES
■ Postoperative pain from PRC generally takes 3 to 6 months to resolve.3,4,16
However, once recovered, nearly all patients will note a significant decrease in
their preoperative pain, and this continues to improve during the first
postoperative year.
■ Patients can expect to regain between 50% and 85% of their contralateral wrist
flexion-extension arc and 75% to 90% of grip strength relative to their
contralateral side.3–5,8,16,17
■ Though the range of motion may be less than preoperatively, the decrease in
patient’s pain provides greater use of the hand, and most patients are
extremely satisfied with the results of PRC.
■ Relative to alternative salvage procedures such as four-corner arthrodesis,
PRC demonstrates better flexion and extension, though less radial deviation
and grip strength.12,18
■ Long-term follow-up of PRC patients more than 10 years demonstrates a 10%
to 15% failure rate with these patients requiring revision surgery for wrist
arthrodesis.3–5,8,16,17,19
■ Younger patients (younger than 40 years of age) and manual laborers have a
higher rate of failure,3,5 though some authors report that 90% of high-demand
patients are still able to function in their occupational capacity.15,16,19
■ All patients will end up with arthritis at the neoradiocarpal joint. However,

most patients will still have good clinical outcomes that do not correlate with
the degree of arthritis.3–5,8,13,16,19
■ Overall, the results of capsular interposition and osteochondral resurfacing
during PRC are similar to those in standard PRC.4,5,13
COMPLICATIONS
■ The advantage of PRC is that it has a low complication rate and does not
require bony union as in the alternative salvage wrist limited fusion procedures.
■ Improper selection of patients may lead to higher failure rates.
■ By far the most common complication of PRC is failure to preserve the RSC
ligament during dissection. This requires prolonged immobilization
postoperatively and leads to a higher likelihood of failure.
FIG 2 • Postoperative (A) PA and (B) lateral radiographs
of a patient after proximal row carpectomy. Note the
appropriate alignment of the capitate in the lunate fossa
of the radius.
REFERENCES
1. Stamm TT. Excision of the proximal row of the carpus. Proc R Soc Med.
1944;38:74-75.

2. Tang P, Swart E, Konopka G, et al. Effect of capitate morphology on contact
biomechanics after proximal row carpectomy. J Hand Surg Am.
2013;38A:1340-1345.
3. Wagner ER, Bravo D, Elhassan B, et al. Factors associated with improved
outcomes following proximal row carpectomy: a long-term outcome study of
144 patients. J Hand Surg Eur Vol. 2016;41(5):484-491.
4. Balk ML, Imbriglia JE. Proximal row carpectomy: indications, surgical
technique, and long-term results. Oper Tech Orthop. 2003;13(1):42-47.
5. Wall LB, Stern PJ. Proximal row carpectomy. Hand Clin. 2013; 29:68-78.
6. Della Santa DR, Sennwald GR, Mathys L, et al. Proximal row carpectomy in
emergency. Chir Main. 2010;29:224-230.
7. Elfar JC, Stern PL. Proximal row carpectomy for scapholunate dissociation. J
Hand Surg Eur Vol. 2011;36E(2):111-115.
8. Chim H, Moran SL. Long-term outcomes of proximal row carpectomy: a
systematic review of the literature. J Wrist Surg. 2012;1:141-148.
9. Van Amerongen EA, Schuurman AH. Proximal row carpectomy: a volar
approach. Acta Orthop Belg. 2008;74:451-455.
10. Culp RW, Talsania JS, Osterman AL. Arthroscopic proximal row carpectomy.
Tech Hand Up Extrem Surg. 1997;1(2):16-19.
11. Weiss ND, Molina RA, Gwin S. Arthroscopic proximal row carpectomy. J
Hand Surg Am. 2011;36A:577-582.
12. Salomon GD, Eaton RG. Proximal row carpectomy with partial capitate
resection. J Hand Surg Am. 1996;21A:2-8.
13. Dang J, Nydick J, Polikandriotis JA, et al. Proximal row carpectomy with
capitate osteochondral autograft transplantation. Tech Hand Up Extrem Surg.
2012;16:67-71.
14. Edouard P, Vernay D, Martin S, et al. Proximal row carpectomy: is early
postoperative mobilization the right rehabilitation protocol? Orthop Traumatol
Surg Res. 2010;96:513-520.
15. Jacobs B, Degreef I, De Smet, L. Proximal row carpectomy with or without
postoperative immobilization. J Hand Surg Eur Vol. 2008;33E(6):768-770.
16. Green DP, Perreira AC, Longhofer LK. Proximal row carpectomy. J Hand
Surg Am. 2015;40(8):1672-1676.
17. Richou J, Chuinard G, Moineau G, et al. Proximal row carpectomy: long-
term results. Chir Main. 2010;29:10-15.
18. Bisneto ENF, Freitas MC, Leomil de Paula EJ, et al. Comparison between
proximal row carpectomy and four-corner fusion for treating osteoarthrosis

following carpal trauma: a prospective randomized study. Clinics.
2011;66(1):51-55.
19. Liu M, Zhou H, Yang Z, et al. Clinical evaluation of proximal row
carpectomy revealed by follow-up for 10–29 years. Int Orthop. 2009;33:1315-
1321.

23
CHAPTER
Section V: Distal Radius
Fractures
Distal Radius Fractures
Shoshana W. Ambani and Kevin C. Chung
DEFINITION
■ Distal radius fractures encompass all fractures of the articular and distal
metaphyseal components of the distal radius.
■ They are the most common fracture of the human skeleton, with an annual
incidence of over 640 000 cases in the United States.
■ These fractures have a bimodal distribution, with peak occurrences in the 5- to
14-year-old and 75- to 84-year-old populations.
■ Fractures of the distal radius distort the normal radiocarpal configuration,
changing the biomechanical properties of the wrist joint.
■ Nonanatomic alignment due to displaced fractures may lead to degenerative
arthritis in the long term.
ANATOMY
■ The distal radius has three concave articular surfaces: the scaphoid fossa,
lunate fossa, and sigmoid notch (FIGS 1 and 2A).
■ The dorsal aspect of the distal radius is convex and acts as a fulcrum for the
extensor mechanism (FIG 2B).
■ The extensor pollicis longus tendon passes ulnar to the Lister tubercle, a
dorsal landmark on the distal radius.

FIG 1 • The distal radius.
■ Hand and forearm tendons and musculature are shown in FIG 3, and the
extensor compartments of the wrist and anatomy of the dorsal wrist capsule are
shown in FIG 4.
■ Important anatomic considerations with regard to surgery of the distal radius
are further delineated in the Techniques section of this chapter.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Patients typically present with tenderness, swelling, and deformity of the wrist
after a fall. Such a fall leads to compressive loading on the extended wrist.
■ The term FOOSH, which stands for “fall on outstretched hand,” is a
commonly used acronym describing this mechanism.
■ Often, the wrist is described as having a “dinner fork deformity” upon
examination (FIG 5).
■ It is important to perform a comprehensive hand and wrist examination while
paying particular attention to any median nerve symptoms that would indicate

the presence of acute carpal tunnel syndrome.
FIG 2 • Volar (A) and dorsal (B) surface anatomy of the
distal radius.
FIG 4 • Dorsal (A) and cross-sectional (B) views of the
six extensor compartments of the wrist. C. Anatomy of
dorsal wrist capsule.

FIG 3 • Tendons and muscles of the dorsal forearm and
hand (A) and the distal volar forearm and wrist (B).
FIG 5 • Dinner fork deformity.
■ Any open injuries should be noted and require urgent debridement.
■ The distal ulna should be examined for dorsal prominence or instability, which
may be indicative of a concomitant distal ulna fracture or a tear of the

triangular fibrocartilaginous complex (TFCC) ligament.
■ The elbow should be examined for tenderness at the radial head and collateral
ligaments. Tenderness in this location may be indicative of a radial head
fracture, elbow dislocation, or other elbow-related injury requiring attention.
IMAGING
■ Standard imaging for all wrist injuries include posteroanterior (PA), oblique,
and lateral radiographs.
■ On PA view, the distal radius has an average slope of 22 degrees in the radial-
to-ulnar plane (radial inclination), with a radial height of about 10 to 12 mm
(FIG 6A). The congruity of the distal radius articulation with the ulna at the
sigmoid notch, as well as the radiocarpal joint itself, must be assessed.
■ On lateral view, the distal radius tilts about 12 degrees in the dorsal-to-volar
plane (volar tilt) (FIG 6B).

FIG 6 • A. Distal radius radial length and radial
angulation. B. Distal radius volar tilt.
■ If significant intra-articular comminution is present, a computed tomography
(CT) scan may provide more information on the location and displacement of
fracture fragments to aid in preoperative planning.
DIFFERENTIAL DIAGNOSIS
■ Distal radius fractures can be differentiated from other wrist injuries, including
the following, by careful examination and review of imaging.
■ Wrist sprain or contusion
■ Radiocarpal dislocation
■ Carpal bone fracture or dislocation, including fractures of the scaphoid
■ Carpal ligament injury, including injury to the scapholunate ligament
■ Fracture of the distal ulna or ulnar styloid
■ Distal radioulnar joint (DRUJ) injury
■ Degenerative arthritis
■ Inflammatory arthritis
■ Septic arthritis
■ Crystalloid arthropathy
■ It is important to rule out other concomitant injuries, such as an acute median
neuropathy.
CLASSIFICATION SYSTEMS AND EPONYMS
■ Once diagnosed, distal radius fractures should be classified as open or closed,
displaced or nondisplaced, and extra-articular or intra-articular. The structural
elements and angles should be further described for clarity of the fracture
pattern.
■ Several classification systems exist for distal radius fractures, including the
Muller AO, Frykman, Melone, Rayhack, Mayo Clinic, and universal
classification systems. Given the plethora of independent classification
systems, their use may complicate communication about fracture patterns. It is
preferable to describe the fracture pattern directly.
■ Eponyms were traditionally used to describe particular distal radius fractures
but now only have historical significance. Common eponyms and nicknames
include the following (FIG 7):
■ A Colles fracture is an extra-articular distal radius fracture featuring an apex

volar deformity with dorsal comminution.
■ A Smith fracture, or “reverse” Colles fracture, is an extra-articular distal
radius fracture with an apex dorsal configuration.
■ A die-punch fracture is an intra-articular depression fracture of the lunate
fossa of the distal radius, resulting from a direct load transmitted through the
lunate.
■ A Barton fracture is an intra-articular shear fracture of the distal radius,
involving a fracture dislocation of the radiocarpal joint, either volarly or
dorsally.
■ A Hutchinson fracture, or “chauffeur’s fracture,” is an isolated intra-articular
fracture of the radial styloid. Chauffeurs often sustained injuries from manual
crank starters that backfired.
INITIAL MANAGEMENT
■ The goal of treating distal radius fractures is to achieve anatomic reduction,
thereby maintaining wrist biomechanics.
■ Initial management of any distal radius fracture requires closed reduction and
immobilization.
FIG 7 • Eponyms and nicknames for distal radius
fractures.
■ This can be done with the use of a “hematoma block,” in which local
anesthetic such as 1% lidocaine is injected dorsally into the fracture site. In
addition, providing the patient with a benzodiazepine can help with muscle
relaxation, thus minimizing deforming forces.
■ The chance of success can be improved further with the use of continuous
intravenous sedation, which provides better muscle relaxation than does a
single benzodiazepine dose.

■ The patient’s index and middle fingers are then placed in finger traps
suspended from an IV pole, with the shoulder abducted 90 degrees and elbow
flexed at 90 degrees (FIG 8A). Weights are applied to the patient’s elbow for
traction (usually 5 to 15 lb), thereby distracting the fracture site.
■ If necessary, a maneuver recreating the injury mechanism to disimpact the
fracture site can be performed, followed by a reduction maneuver (FIG 8B).
■ Notably, with simple distraction and sedation, the fracture often autoreduces
without significant manipulation.
■ A mini C-arm is employed to determine the adequacy of closed reduction in
real time.
■ Once reduction is achieved, with the patient still in finger traps, a sugar-tong
splint is applied to stabilize the fracture site by preventing wrist flexion-
extension and supination-pronation.
■ Postreduction films are imperative.
FIG 8 • A. General setup for closed reduction of a distal
radius fracture. B. Reduction maneuver for dorsal
displaced distal radius fractures. First, the wrist joint is
placed in traction. Then, the physician’s thumb is used
to push the distal fragment volarly into alignment.
■ If closed reduction is successful, strict immobilization over the next 6 to 8
weeks can lead to adequate fracture healing, obviating the need for surgery.

■ An unstable fracture will not be maintained in a splint, however, and surgery
should be considered pending patient circumstances.
NONOPERATIVE MANAGEMENT
■ Nonoperative management consists of splinting or casting of stable fracture
patterns. These are typically nondisplaced or minimally displaced fractures, or
fractures that are well reduced.
■ The patient’s age, medical comorbidities, and functional level should be
considered in determining whether or not to pursue nonoperative management
vs surgical intervention.
■ Patients being treated nonoperatively should be monitored with weekly
radiographs for loss of reduction.
■ A volar tilt of 0 to 11 degrees dorsal tilt, radial shortening of 5 mm, and
articular incongruity of 1 mm can be tolerated.
■ Typically, the patient can be switched to a short-arm cast at 2 to 3 weeks for
the remainder of the healing period.
■ Early range of motion (ROM) of nonimmobilized joints is essential to prevent
contracture. The cast should not extend past the metacarpophalangeal joints to
allow finger ROM.
SURGICAL MANAGEMENT
■ The goal of treatment is to restore anatomical alignment, thereby maintaining
normal wrist biomechanics and decreasing the risk of developing degenerative
arthritis.
■ Indications for surgery include but are not limited to
■ Articular incongruity more than 1 to 2 mm
■ Radial shortening more than 5 mm
■ Dorsal tilt more than 10 to 20 degrees
■ Extensive comminution
■ Open fractures
Preoperative Planning
■ Patient comorbidities must be assessed.
■ Healthy patients are often given a regional block with intravenous sedation by
the anesthesia team.
■ Imaging should be thoroughly reviewed to develop a concrete operative plan.
■ If the patient presents with median nerve symptoms, a concomitant carpal

tunnel release should be considered.
FIG 9 • Hand table setup.
Positioning
■ Procedures on the distal radius are done on a hand table, with the surgeon
seated (FIG 9).
■ The patient is positioned supine on the operating bed as near to the hand table
as possible.
■ A tourniquet is placed on the upper arm.
Approach
■ Surgical options for the treatment of distal radius fractures include
percutaneous Kirschner wire (K-wire) fixation, external fixation, volar plate
fixation, dorsal plate fixation, and dorsal bridge plate fixation.
■ Percutaneous pinning with K-wires is indicated for unstable, displaced extra-
articular distal radius fractures, simple intra-articular distal radius fractures,
and displaced distal radius fractures in children and adolescents.
■ External fixation uses ligomentotaxis to reduce and stabilize fracture
fragments. Indications include unstable, irreducible extra-articular fractures,
displaced intra-articular fractures that can be reduced in a closed or
percutaneous fashion, and highly comminuted fractures that are openly reduced
and fixed with plates or pins but require further carpal unloading to promote

healing. External fixation can be used as an adjunct to other fixation techniques
should further stabilization be required.
■ Volar-locking plate fixation is indicated for unstable, displaced extra-articular
fractures, displaced intra-articular fractures, and volar shearing fractures. The
introduction of volar-locking plating techniques has revolutionized the
treatment of distal radius fractures by allowing early return of activity and by
avoiding the problems of dorsal plating.
■ Dorsal plating can be difficult in the presence of dorsal comminution and is
associated with a higher rate of postoperative extensor tendon injury, adhesion,
or rupture. Dorsal plate fixation is generally reserved for dorsal shear fractures
or lunate facet fractures involving the dorsal cortex.
■ Dorsal bridge plate fixation is designated for highly comminuted, intra-
articular distal radius fractures, including those associated with significant
metaphyseal and diaphyseal comminution, in particular subsets of patients:
■ Polytrauma patients with impaired ability to conduct activities of daily living
■ Patients who refuse external fixation for psychological or aesthetic concerns
■ Patients with extensive tendon injuries that will require multiple procedures
followed by soft tissue and bony healing over an extended period of time
■ Patients with severe osteoporosis
• For patients with osteoporosis and severe comminution of the distal radius,
the bridging plate serves as an internal distractor that permits healing of the
comminuted bone while giving the patient the latitude for self-care, with the
bridging plate stabilizing the wrist.
• At 2 to 6 months, when the distal radius has healed, the plate is removed
and the patient can initiate wrist motion to regain mobility.
T E C H N I Q U E S
■ Percutaneous Pinning
Equipment
■ A tourniquet is not usually needed, although some surgeons advocate for its
use to minimize soft tissue swelling during the procedure, thereby allowing
improved palpation of bony landmarks.
■ The pins are typically 0.062 in. K-wires, which are driven into bone using a

power hand drill (TECH FIG 1).
■ An intraoperative C-arm is required to assess fracture configuration and pin
placement throughout the procedure.
Procedure
■ We prefer the intrafocal Kapandji technique for percutaneous pinning of
distal radius fractures, particularly if the bone is osteopenic and brittle.
■ A K-wire is introduced dorsally into the fracture site as a lever to restore
volar tilt (TECH FIG 2A,B).
TECH FIG 1 • A power hand drill is used to insert K-
wires.

TECH FIG 2 • The Kapandji intrafocal technique. A. A
K-wire is placed dorsally into the fracture site. B. The

distal fragment is levered volarly with the K-wire to
achieve reduction. C,D. AP and lateral fluoroscopic
intraoperative views showing placement of the pins. E.
K-wire pins in place.
■ Once fracture reduction is achieved, one or two more K-wires are driven into
the intact volar cortex at the same level, thereby buttressing the reduction. In
a similar manner, the fracture can be levered radially to restore radial
inclination.
■ This is followed by placement of an additional buttressing K-wire.
■ Once the fracture is stabilized by this buttressing technique, traditional
pinning from the radial styloid and from the dorsoulnar aspect of the radius
through the fracture fragments can proceed (TECH FIG 2C–E).
Postoperative Care
■ Patients are seen 2 weeks postoperatively in clinic for splint takedown,
dressing change, and suture removal.
■ A removable volar splint is applied.
■ Gentle finger, wrist, and elbow ROM is allowed at this time.
■ Serial x-rays are obtained at clinic visits to ensure stable bony alignment.
■ In adults, K-wires are removed in the office at 5 to 6 weeks.
■ In pediatric patients, K-wires can be removed as early as 4 weeks,
depending on radiographic and clinical signs of healing.
■ Pin-track infection can lead to early removal of the pin, and if the infection is
not treated or recognized, deep osteomyelitis can cause devastating problems.
■ Patients must be taught to clean the pin site meticulously twice a day with
hydrogen peroxide on a cotton-tip applicator and then to seal the pin entry
site with bacitracin ointment.
■ External Fixation
Equipment
■ A variety of external fixator systems for treatment of distal radius fractures
exist through different manufacturers. The surgeon must select an external
fixator, and the instruction manual must be studied prior to use in the

operating room.
■ A tourniquet is useful to help maintain hemostasis during the procedure,
particularly if done in conjunction with internal fixation.
■ A C-arm is required intraoperatively to assess fracture configuration and pin
placement.
Pertinent Anatomy
■ The external fixator is placed parallel to the dorsoradial surface of the wrist,
using pins at the proximal and distal ends.
■ The distal pins are placed in the second metacarpal.
■ The proximal pins are placed in the radial shaft, approximately 10 cm or
one hand’s breadth proximal to the radial styloid. This is the location of the
abductor pollicis longus (APL) and extensor pollicis brevis (EPB) muscles
as they traverse the radial shaft.
■ One must have a solid understanding of the dorsal hand and forearm tendons
and musculature (see FIG 3A) and the extensor compartments of the wrist
(see FIG 4A).
Fracture Reduction
■ The forearm is pronated on the hand table.
■ The fracture is first reduced under fluoroscopic guidance.
■ Percutaneous 0.062 in. K-wires may be placed dorsally as well as through
the radial styloid to help maintain the reduction (TECH FIG 3).
Pin and External Fixation Frame Placement
■ A 2-cm longitudinal incision is made dorsoradially just proximal to the APL
and EPB tendons, about a hand’s breadth proximal to the radial styloid.
■ Care is taken to visualize and protect the superficial radial nerve in this
area.
■ The first pin of the external fixator is inserted into the radial shaft in the deep
interval between the extensor carpi radialis longus (ECRL) and extensor carp
radialis brevis (ECRB) tendons.
■ Then a 2-cm longitudinal incision along the dorsoradial aspect of the second
metacarpal is made, taking care to retract and protect the extensor tendons
and first dorsal interosseous muscle.
■ The second pin is placed through this incision.
■ The external fixation frame is then slid into place over these initial two pins

and tightened.
■ Using the open slots on the frame, the positions of the remaining two pins
are marked, one in the metacarpal and one in the radial shaft.
■ These pins are then inserted at these locations (TECH FIG 4A).
TECH FIG 3 • A. Fluoroscopy shows fracture
reduction with K-wire pins in place. B. Pins in place
through small wrist incisions.

TECH FIG 4 • A. External fixator pin placement. B.
Final placement of external fixator. C. Postoperative
radiograph. D. Testing DRUJ instability.
■ The external fixator frame is then further tightened to stabilize the reduction
(TECH FIG 4B,C).
■ At this point, all fingers should have passive flexion and extension, and the
wrist should not be placed in excessive flexion or ulnar deviation.
■ The DRUJ is also assessed for stability (TECH FIG 4D).
■ With the elbow flexed at 90 degrees on the hand table, displacement in the
dorsal-palmar direction is tested in neutral position, supination, pronation,
and radial deviation. Radial deviation should stabilize the DRUJ unless
there is a disruption of the triangular fibrocartilaginous complex (TFCC).
■ DRUJ instability is defined as more than 8 mm of ulnar translation relative
to the radius in the dorsal-palmar direction.
■ If unstable, the distal ulna is reduced and pinned to the radius.

■ If a large ulnar styloid fracture is noted, this can be fixed with a K-wire.
Completion and Closure
■ Simple, interrupted 4-0 nylon sutures are used to close the skin incisions,
taking care to avoid injuring the branches of the superficial radial nerve.
■ Nonadherent dressings are applied to the pin sites.
■ A thick layer of gauze is used to push the skin down from being tented on
the pins.
■ A volar splint is applied for additional support.
Postoperative Care
■ The splint and dressings are removed 7 to 10 days postoperatively to
evaluate the pin sites and skin incisions. Sutures are removed.
■ Finger ROM is encouraged.
■ Nonadherent dressings are applied to the pin sites for the first 3 weeks. If
there is drainage, half-strength peroxide is used on a cotton-tipped applicator
to clean the sites daily.
■ If percutaneous K-wires were placed to stabilize the reduction, they can be
removed in the office after 3 to 4 weeks while the external fixator is left in
place.
■ The patient can shower with the external fixator in place once all sutures and
percutaneous K-wires are removed and incisions are dry.
■ The external fixator is removed in the office after 4 to 6 weeks once the
fracture has healed on clinical and radiographic examination.
■ Volar Plating
Equipment
■ A tourniquet is used for this procedure.
■ Bipolar cautery is useful for coagulating crossing vessels during exposure.
■ A number of volar-locking plate systems exist. The surgeon must select a
plating system and review the instruction manual thoroughly prior to use in
the operating room. Particular attention must be paid to the distal locking
screw trajectory for proper plate placement.
■ The C-arm is required intraoperatively to assess fracture configuration and
hardware placement throughout the procedure.

Pertinent Anatomy
■ The surgical interval is between the flexor carpi radialis (FCR) tendon and
the radial artery and brachioradialis (BR) tendon (see FIG 3B).
■ The median nerve lies in the plane between the flexor digitorum superficialis
(FDS) and flexor digitorum profundus (FDP) muscle bellies in the forearm
before emerging between FDS and flexor pollicis longus (FPL) more distally,
entering the carpal tunnel at the wrist crease just deep to palmaris longus
(PL).
■ The palmar cutaneous branch of the median nerve arises 5 cm proximal to
the wrist crease, between the PL and FCR. Notably, PL is absent in about
15% of the population.
■ The FPL muscle overlies the pronator quadratus (PQ) and must be swept
from radial to ulnar to expose PQ surgically.
■ The PQ muscle is divided along its radial border and elevated to expose the
bony surface of the distal radius and the associated fracture.
■ The BR inserts into the distal radius and is often released during the
procedure to decrease the deforming forces on the distal fragment, aiding
fracture reduction.
Exposure
■ The forearm is supinated on the hand table.
■ A 6- to 8-cm incision is made at the radial aspect of the volar forearm
between the FCR and the radial artery, ending just short of the wrist crease. If
more distal exposure is required, the incision can be extended with a V-
shaped zigzag (TECH FIG 5A).
■ The FCR tendon sheath is entered, and the dissection proceeds along its
radial aspect, to avoid the palmar cutaneous branch of the median nerve that
is ulnar to the FCR, through the posterior sheath to expose the FPL muscle
belly.
■ The FPL is then swept ulnarly, exposing the PQ (TECH FIG 5B). The radial
artery is also identified and retracted radially.
■ An L-shaped incision is made through the PQ, releasing it radially and
distally from the radius (TECH FIG 5C).
■ The PQ is elevated to expose the fracture site (TECH FIG 5D).
■ The BR tendon can also be released at this point to further expose the distal
fragment, which is usually displaced dorsally.

Fracture Reduction and Plate Fixation
■ Next, fracture reduction is performed and may be provisionally held with K-
wires.
TECH FIG 5 • A. Skin incision with FCR exposed. B.
The PQ is exposed. C. The PQ is cut radially and
distally in an L shape. D. The distal radius is exposed.

TECH FIG 6 • A. Volar plate placement. B,C.
Intraoperative fluoroscopic images confirm appropriate
plate placement.
■ The volar plate is selected and placed centrally and distally on the radial
shaft to capture the distal fragment.
■ A screw is centrally placed through the elliptical plate hole into the radial
shaft.
■ Although sizes can differ based on plating system, typically, a 2.0-mm drill
bit is used, allowing for insertion of a 2.7-mm screw.
■ Plate placement is then evaluated with C-arm fluoroscopy.

■ By loosening the shaft screw, the plate can be shifted proximally or distally
as needed.
■ Once proper plate placement is achieved, the shaft screw is retightened. A
second shaft screw is then inserted.
■ With the wrist flexed, the distal screws are then placed, typically with a 1.8-
mm drill bit and 2.4-mm screws.
■ Locking screws can be used if the fracture is already properly reduced.
■ However, if some separation exists between the distal fragment and the
plate, a nonlocking screw can be placed initially to draw the bone to the
plate.
TECH FIG 7 • A. The PQ is reattached, covering most
of the plate. B. Skin closure.
TECH FIG 8 • A,B. AP and lateral postoperative

radiographs.
■ Once the distal fragment is properly stabilized with a sufficient number of
screws, the initial nonlocking screw can be exchanged for a locking screw, if
desired (TECH FIG 6A).
■ At this point, the provisional K-wires can be removed or left in place for 3
weeks if additional support is deemed necessary.
■ Fluoroscopy is used to confirm appropriate plate placement (TECH FIG
6B).
Completion and Closure
■ If the BR was released, it can be reattached with a step-cut lengthening
maneuver.
■ The PQ is then brought back over the plate and is sutured to the BR fascia
using 3-0 Vicryl suture (TECH FIG 7A).
■ The wound is closed with 3-0 Vicryl suture for the deep dermal layer,
followed by a running subcuticular 3-0 Monocryl for the skin (TECH FIG
7B).
■ A short-arm volar splint is placed for additional support, leaving the fingers
free for ROM.
Postoperative Care
■ Aggressive finger ROM is initiated immediately after surgery to decrease
edema and avoid stiffness.
■ The patient is evaluated in the clinic 10 to 14 days after surgery with repeat
radiographs (TECH FIG 8), at which time gentle wrist ROM is initiated.
■ Dorsal Plate Fixation
Equipment
■ A tourniquet is used for this procedure.
■ A dorsal T- or L-shaped plate of an appropriate length must be selected. This
plate is typically a 2.4-mm low-profile plate.
■ A C-arm is used intraoperatively to evaluate fracture configuration and
assess hardware placement.

Pertinent Anatomy
■ The extensor retinaculum divides the extensor tendons into six dorsal
compartments and serves to prevent tendon bowstringing (see FIG 4A,B).
■ The ECRL/ECRB tendons lie in the second extensor compartment.
■ Care must be taken in this area to avoid injury to the radial sensory nerve
and dorsal radial artery.
■ The extensor pollicis longus (EPL) tendon lies in the third extensor
compartment, passing in a groove ulnar to Lister tubercle.
■ It must be released and mobilized to expose the dorsal distal radius.
■ The extensor indicis proprius (EIP) and extensor digitorum communis
(EDC) tendons lie in the fourth extensor compartment.
■ They are elevated subperiosteally, thereby minimizing tendon contact with
dorsally placed hardware.
■ The fourth extensor compartment also contains the terminal branch of the
posterior interosseous nerve (PIN), which traverses the floor along its radial
aspect and can be sacrificed without clinical import.
■ The distal radius articulates with the scaphoid and lunate via two hyaline-
covered concave facets.
■ The two most important ligaments associated with the dorsal wrist capsule
are the dorsal radiocarpal (DRC/radiotriquetral) and dorsal intercarpal
(DIC/scaphotriquetral) ligaments (see FIG 4C).
Exposure
■ A 6- to 8-cm longitudinal incision on the dorsal wrist is made in line with the
third metacarpal, just ulnar to Lister tubercle between the third and fourth
extensor compartments (TECH FIG 9).

TECH FIG 9 • Planned incision on wrist.
■ Care is taken to preserve the branches of the superficial radial nerve.
■ Full-thickness flaps are raised to expose the extensor retinaculum.
■ The third compartment is longitudinally incised, exposing the EPL tendon.
■ The EPL tendon is released from its groove, and the retinaculum is divided
between the septa of the third and fourth compartments.
■ A periosteal elevator is used to elevate the fourth compartment in the
subperiosteal plane to expose the bony surface.
■ A longitudinal capsulotomy may be required to expose the articular surface,
which is performed by releasing the dorsal capsular insertions from the distal
nonarticular lunate.
■ Once the fracture site and articular surface are exposed, Lister tubercle
should be removed with a rongeur to allow the plate to sit flush on the dorsal
cortex.
Fracture Reduction and Plate Fixation
■ Fracture reduction is then accomplished with provisional K-wire fixation.
■ A T-shaped plate is selected and contoured.
■ Fluoroscopy is used to adjust the position of the plate proximally or distally
as needed.
■ Articular congruity is confirmed with fluoroscopy.
■ The screws are applied sequentially to finalize plate (TECH FIG 10).
■ Once the fracture is stabilized, the DRUJ is assessed for instability.

■ If deemed unstable, the DRUJ should be pinned percutaneously with the
forearm in supination.
Completion and Closure
■ The dorsal capsule and extensor retinaculum are closed with 3-0 and 2-0
nonabsorbable suture, respectively.
■ The EPL tendon should remain in its new position superficial to the
retinaculum.
■ The skin is closed with simple interrupted 3-0 nylon suture.
■ A volar splint leaving the thumb and fingers free is applied for postoperative
comfort.
Postoperative Care
■ The splint is removed at the first postoperative visit in 7 to 10 days, and
active and passive finger ROM exercises are initiated.
■ A removable short-arm volar splint is applied in neutral position, to be
removed 5 to 7 times daily for wrist ROM exercises.
■ A compression garment is applied for postoperative edema control.
■ The splint can be weaned at 4 weeks to allow for activities of daily living.
■ Once fracture healing has completed at about 6 to 8 weeks (TECH FIG 11),
the splint is permanently discontinued.
■ However, if DRUJ instability was addressed in the procedure, the
postoperative immobilization period is extended.

TECH FIG 10 • A. In situ plate placement. B–D. AP,
lateral, and close-up lateral fluoroscopic views,
respectively, showing final plate placement.

TECH FIG 11 • A–C. AP, oblique, and lateral
postoperative radiographs.
■ Dorsal Bridge Plate Fixation
Equipment
■ A tourniquet is used for this procedure.
■ A distal radius bridge plate of an appropriate length must be selected. This
plate is typically a 2.4-mm combination plate with smooth, beveled edges.
■ If such a plate is not available, a 2.7- or 3.5-mm limited contact dynamic
compression plate (LC-DCP) can be used.
■ A C-arm is used intraoperatively to help plan surgical incisions, evaluate
fracture configuration, and assess hardware placement.
Pertinent Anatomy
■ Dorsal bridge plate fixation is designated for highly comminuted, intra-
articular distal radius fracture (TECH FIG 12).
■ When placed, the bridge plate passes superficial to the joint capsule and
periosteum within the second extensor compartment.

■ The extensor tendons overlying the index finger metacarpal must be
retracted to facilitate distal fixation of the bridge plate.
■ The proximal portion of the bridge place is placed along the dorsoradial
aspect of the radial shaft, adjacent to the BR.
Site Preparation and Exposure
■ Fluoroscopy is used to mark the location of the proximal extent of the plate
over the radial shaft, which should allow the placement of three screws at
least 4 cm proximal to the fracture site.
■ The distal end of the plate should overlie the third or second metacarpal, no
farther than the metacarpal neck.
■ These landmarks should guide incision placement.
■ Two or three small longitudinal incisions are made dorsally to facilitate
exposure (TECH FIG 13A).
■ A 4-cm incision is made over the dorsal midshaft of the index finger
metacarpal. The extensor tendons are identified and retracted (TECH FIG
13B).
■ A second 4- to 6-cm incision is made dorsoradially overlying the radial
shaft, just proximal to the EPB and APL muscles. The ECRL and ECRB
tendons are identified and the radial shaft is exposed, allowing for
placement of three screws at least 3 to 4 cm proximal to the fracture.

TECH FIG 12 • A,B. PA and lateral radiographs
showing comminuted intra-articular distal radius
fracture.
■ A third separate 3-cm incision over Lister tubercle may also be made if an
articular reduction or metaphyseal bone grafting is needed. The EPL tendon
is mobilized to facilitate exposure and reduction.
Placement of the Plate
■ Metzenbaum scissors are inserted, proximal to distal, along the floor of the
second extensor compartment to create a tunnel, ensuring that the periosteum
and joint capsule remain deep to the tunnel.
■ The plate is then passed from the distal incision to the proximal incision
(TECH FIG 14A), staying deep to the index finger extensor tendons.
■ Manual traction of the wrist is used to obtain provisional reduction of the
fracture, restoring radial length and inclination.
■ Under fluoroscopy, the plate is aligned centrally over the index metacarpal
and radial shaft.
■ A bicortical screw is placed in the penultimate hole at the midline of the

metacarpal shaft.
■ While traction is reapplied under fluoroscopy to confirm fracture and plate
alignment, the proximal end of the plate is clamped to the radial shaft using
serrated bone-holding clamps.
TECH FIG 13 • A. Planned incisions. B. Incision over
index finger metacarpal.

TECH FIG 14 • A. Dorsal plate placement.
Intraoperative fluoroscopic images showing fixation at
the second metacarpal (B) and at the radial shaft (C).
■ Fluoroscopy and clinical assessment are necessary to ensure restoration of
radial length, radial inclination, and volar tilt, as well as absence of rotational
abnormalities.
■ Supination and pronation of the forearm should be assessed to confirm full
ROM.
■ When plate position is deemed appropriate, three bicortical screws are
placed proximally in the radial shaft, securing the plate.

■ Two additional bicortical screws are applied to the metacarpal, for a total
of three distal points of fixation.
■ Fluoroscopy is used to check plate placement (TECH FIG 14B,C).
Additional Fracture Reduction and Fixation
■ Once the dorsal bridge plate is in place, any diaphyseal fragments amenable
to lag screw fixation can be fixated to the radial shaft.
■ If any further reduction of the articular surface is required, the third incision
(explained above) can be used to release the EPL tendon and pass the plate.
■ A dental pick can be used to reduce the articular incongruity.
■ If possible, a 2.7-mm cortical screw is inserted through the plate directly
under the lunate fossa as a buttress against subchondral collapse.
■ Grafting with bone or allograft can also be performed to achieve subchondral
and metaphyseal support of the articular reduction.
■ K-wires (0.045 or 0.062 in.) can also be placed percutaneously to hold small
articular fragments in reduction.
Completion and Closure
■ Incisions are typically closed with 3-0 Vicryl sutures for the deep dermal
layer, followed by a subcuticular running 3-0 Monocryl for the skin.
■ A bulky dressing and volar wrist splint are applied for additional support,
leaving fingers free for immediate active and passive ROM exercises.
Postoperative Care
■ Active and passive digital ROM exercises are encouraged throughout the
healing process.
■ The first postoperative visit with radiographic films is at 7 to 10 days
(TECH FIG 15), at which time a compression garment is applied to control
edema, and a thermoplastic short-arm splint is provided.
■ If K-wires were placed, they can be removed at 6 weeks.
■ Patients may use the operated extremity for activities of daily living.
■ Finger ROM, pronation, and supination are encouraged.
■ Patients should not lift more than 5 lb. As long as restrictions are
maintained, patients may return to work.
■ Hardware removal can be scheduled at about 8 to 12 weeks after surgery,
once bony healing has been achieved.
■ Finger and wrist ROM exercises are initiated immediately after plate

removal.
TECH FIG 15 • A,B. PA and lateral postoperative
radiographs of dorsal bridge plate in place.
PEARLS AND PITFALLS
PERCUTANEOUS PINNING
General K-wire
technique
■ Avoid multiple K-wire passes to prevent further fragmentation
of fracture pieces, particularly in osteopenic bone.
Percutaneous
pinning
technique
■ For pin placement, the authors prefer using a small longitudinal
incision over the radial styloid to avoid skewering branches of
the superficial radial sensory nerve and the extensor tendons.
■ If the pins are placed percutaneously, caution is advised, as
nerves and tendons can be easily damaged.
Adjunctive
external
■ Consider concomitant external fixation in patients greater than
55 y of age and in younger patients if both the dorsal and volar

fixation
cortices are comminuted.
Over-reduction
■ Avoid over-reducing the fracture fragment, as excessive volar
flexion can displace the fragment volarly.
Pediatric distal
radius
fractures
■ Often, pediatric fractures can be reduced and stabilized with a
single K-wire.
EXTERNAL FIXATION
Alignment of
external fixator
■ The external fixator should be aligned at about 45 degrees
dorsally from the radial midlateral axis.
■ This dorsoradial position for external fixator placement should
allow for full thumb ROM, particularly thumb retropulsion, with
the fixator in place.
■ Postoperative radiographs can also be obtained without
obstruction by the fixator in this position.
General pin
placement
■ Pins should be bicortical and stable prior to external fixator
frame placement.
■ If the bone is weak and osteopenic, the proximal metacarpal pin
may be placed through the second metacarpal base into the third
metacarpal base for further stability. However, if the metacarpal
pins are placed too deep, the motor branch of the ulnar nerve
may be injured.
■ When the proximal pins are placed between the ECRL and
ECRB tendons into the radial shaft, the ECRL tendon acts as a
protective barrier between the superficial radial nerve and the
pins.
Percutaneous
approach
■ If the external fixator pins are placed percutaneously, whether in
the radial shaft or in the second metacarpal, the superficial radial
nerve can inadvertently be injured.
■ The authors prefer using small incisions for direct visualization
and protection of the nerve branches.
External fixator
frame
placement
■ Avoid overdistraction of the frame, as this may lead to wrist
stiffness or limited finger ROM.
■ If the external fixator is placed in excessive flexion and ulnar
deviation, carpal tunnel symptoms may occur.
■ External fixators can be used to supplement the fixation of
highly comminuted distal radius fractures with percutaneous pins
or internal plating. External fixation serves to off-load the carpus
during the healing process.

VOLAR PLATING
Exposure
■ Avoid soft tissue stripping too far distally on the radius, as
inadvertent release of the volar carpal ligaments will result in
carpal instability.
■ Mobilizing the radial artery and ligating its ulnar-crossing
branches will help to minimize bleeding and permit better
exposure of the BR for release.
■ Avoid dissection ulnar to the FCR tendon, as the palmar
cutaneous branch of the median nerve can be injured.
Release of the
BR tendon
■ Not always necessary
■ Can be useful in fracture reduction
■ Dissection must proceed entirely on bone to avoid damage to the
tendons of the first extensor compartment.
■ At the end of the procedure, the BR can be reattached using a
step-cut lengthening maneuver.
Fracture
reduction
■ A Freer elevator can be used to lever the distal fragment into
place. It must be inserted through the fracture site into the dorsal
cortex for complete disimpaction of the distal fragment to permit
proper reduction.
■ Flexing the hand and wrist can promote reduction.
■ A large towel bump under the hand and distal fragment may be
useful in the reduction maneuver.
■ Avoid over-reduction of the fracture, which can lead to volar
displacement.
Intraoperative
imaging
■ The C-arm is used to assess plate and screw placement.
■ The AP view confirms proper radioulnar placement of the plate.
■ The lateral view confirms proper proximal-distal placement of
the plate.
■ A fossa lateral view, which is taken by holding the forearm at 22
degrees from the plane of the hand table, allows visualization of
the radiocarpal joint space to ensure no screw penetration.
Screw
placement
■ Avoid placing screws that are too long, as they may cause
attritional extensor tendon rupture. The distal locking pegs or
screws must be about 2 mm short of reaching the dorsal cortex.
■ Avoid screw penetration into the radiocarpal joint and DRUJ.
■ The distal screws are designed for subchondral support (distal
row) and for dorsal fixation (proximal row) of the distal
fragment.
Reattachment
■ Often cannot be fully reattached due to plate prominence

of the PQ
■ Partial closure allows for some soft tissue coverage of the plate.
■ Avoid inadvertent suturing of the first extensor compartment
tendons.
■ Some surgeons do not suture the PQ back into place at all.
Volar plate
removal
■ Approximately 15%–20% of volar plates are eventually
removed.
■ Reasons for removal of hardware included tenosynovitis, tendon
rupture, pain, and prominent or intra-articular hardware.
DORSAL PLATING
Exposure
■ Full-thickness flaps are elevated, including skin, subcutaneous
tissue, and superficial fascia. These flaps will contain and protect
the dorsal sensory branches of the ulnar and radial nerves.
■ Elevating the fourth compartment in the subperiosteal plane
minimizes plate contact with the extensor tendons.
■ Small incisions for provisional K-wire placement in the area of
the radial sensory nerve are recommended to avoid damaging the
nerve branches.
Dorsal
capsulotomy
■ Can be performed to address fractures involving the articular
surface.
■ Involves a longitudinal incision that detaches the dorsal capsular
insertions from the distal nonarticular lunate.
■ The intercarpal ligaments must be protected.
■ Avoid entering the DRUJ. Radioulnar instability can result if the
dorsal radioulnar ligament is divided.
Lister tubercle
■ The EPL tendon passes in a groove just ulnar to the Lister
tubercle.
■ Lister tubercle is removed with rongeurs such that the plate can
sit flush with the dorsal cortex and be less prominent.
Bone grafting
■ Cancellous bone grafting of metaphyseal defects can help
support an articular reduction.
Screw
placement
■ Avoid placing screws that are too long, as this can lead to
irritation of volar structures.
DORSAL BRIDGE PLATE FIXATION
Incisions
■ Fluoroscopy is used to guide placement of incisions.
■ By holding the distal end of the plate at the index metacarpal
neck-shaft junction, the proximal extent of the plate can be
marked over the radial shaft. One must ensure that 3 screws can
be placed at least 3 to 4 cm proximal to the fracture.

■ A third incision over the Lister tubercle can be made for articular
reduction and metaphyseal bone grafting, if necessary.
Dorsal bridge
plate
placement
■ The plate is placed along the floor of the second extensor
compartment, deep to the index finger extensors and wrist
extensors and superficial to the periosteum.
■ The plate should not extend distal to the index metacarpal neck.
■ The distal screw must be in the midline of the index metacarpal
shaft to avoid rotary displacement of the fracture.
■ Applying traction with the forearm in 45–60 degrees of
supination before applying the serrated clamp is helpful to avoid
pronation of the distal fragment.
Overdistraction
■ Defined as a radiocarpal gap greater than 5 mm.
■ Can lead to loss of finger ROM secondary to extrinsic extensor
tightness
■ Can lead to development of complex regional pain syndrome
(CPRS).
Articular
reduction and
bone grafting
■ Failure to reduce articular fragments can lead to symptomatic
radiocarpal arthrosis.
■ If an articular reduction is performed, bone grafting provides
subchondral and metaphyseal support of the reduction.
■ Contraindications to bone grafting:
■ Open fractures with gross contamination
■ Soft tissue defects precluding primary wound closure
DRUJ
instability
■ Defined as greater than 8 mm of palmar to dorsal translation of
the ulna relative to the radius
■ Should be suspected in cases with large ulnar styloid fractures or
displaced ulnar head fractures
■ After bridge plate placement, the DRUJ should be assessed for
instability.
■ If DRUJ instability is detected, the forearm should be
immobilized in supination for 3–4 wk.
Bridge plate
removal
■ Plate removal can be electively scheduled at 8–12 wk after the
initial surgery.
■ The plate should stay in place until radiographic osseous healing
has occurred. Bridging callous should be seen in both the sagittal
and coronal planes.
■ Bony healing may be difficult to visualize with a thick 3.5-mm
plate in place.
■ Early removal of the plate can lead to fracture collapse.
■ Late removal of the plate may lead to extensor tendon attrition

and rupture or permanent wrist stiffness.
OUTCOMES
■ Excellent long-term outcomes have been reported for all techniques when used
in the appropriate patients.1 Indeed, patient selection is critical.
■ Over the past decade, however, internal fixation has become increasingly
popular due to perceived early functional benefits.
■ Of the internal fixation options, volar plates are favored over dorsal plates due
to fewer tendon-related complications.
■ With regard to external vs internal fixation, studies have shown no significant
differences in grip strength, wrist ROM, radiographic alignment, and pain.
■ Still, the existing literature is heterogeneous with respect to reported outcomes
for the treatment of distal radius fractures. As such, a unified approach has
been recently proposed to integrate performance, patient-reported outcomes,
pain, complications, and radiographs.2
■ For the elderly population, management of distal radius fractures has
traditionally been dominated by closed reduction and immobilization.
■ Nonoperative management was found to achieve satisfactory functional
outcomes despite the presence of fracture malalignment.
■ However, today’s elderly population is more active than prior generations,
which may indicate the need for more accurate fracture fixation for
maintaining function. A multicenter prospective study to further investigate
outcomes in this population is currently under way.
COMPLICATIONS
■ The overall complication rate after fixation of distal radius fractures has been
reported to be as high as 30%.3
■ Pin-track or superficial infections associated with external fixation are the
most common type of postoperative infection following distal radius fixation,
with an overall incidence of 25%.
■ Staphylococcus aureus is the most commonly isolated microbe.
■ Nearly all reported infections resolve with oral antibiotics, with or without
pin removal.
■ Internal fixation of distal radius fractures, whether volar or dorsal, has lower
infection rates, only up to 3%.
■ Open fractures of the distal radius, regardless of fixation method, are

associated with a higher rate of infection of 44%.
■ Clinically relevant extensor tendon injury or rupture is uncommon for both
percutaneous pinning and external fixation, less than 1%. The use of small
incisions to facilitate direct visualization and protection of important structures
during pin placement is generally advocated.
■ EPL rupture is, however, a well-documented complication of volar plating,
with an incidence of 2% to 9%. It is typically caused by drill bit penetration or
prominent dorsal screw tips. EPL rupture can also occur with nonoperative
treatment. It is believed that the EPL near the Lister tubercle has poor intrinsic
vascularity, and when combined with nutritional interference from hematoma,
delayed EPL rupture ensues. Should EPL rupture occur, reconstruction can be
performed with tendon grafting or an EIP tendon transfer.
■ Extensor tenosynovitis may also occur with prominent dorsal screw tips from
volar plating, with an incidence of up to 14%. This is addressed with
hardware removal. In particular, dorsal plating is associated with an
unacceptably high rate of extensor tendon complications, ranging from 19%
to 48%. The advent of ultra–low profile plates appears to have decreased the
incidence of such complications.
■ Flexor tendon injury is less common than extensor tendon injury following
fixation of distal radius fractures and is mostly associated with volar plating.
■ The FPL is the most frequently ruptured flexor tendon.
■ Flexor tenosynovitis may occur and may be treated with implant removal.
■ Some surgeons advocate repair of the PQ as a protective layer between volar
hardware and flexor tendons.
■ Carpal tunnel syndrome, or median neuropathy, can occur acutely, subacutely,
or in a delayed fashion after distal radius fractures regardless of treatment
method, operative or nonoperative, with an overall incidence of 8.5%.
■ Some surgeons advocate carpal tunnel release in all distal radius fractures
undergoing fixation, whereas others limit this to patients with pre-existing or
acute signs of median neuropathy.
■ Superficial radial nerve (SRN) injury is most common with percutaneous
pinning and external fixation, with an incidence of 4% to 13%. Using small
skin incisions to facilitate direct visualization and preservation of the nerve
branches during pin placement reduces this risk.
■ Complex regional pain syndrome has been associated with distal radius
fractures treated both operatively and nonoperatively, with rates ranging from

3% to 25%.
■ It is characterized by unexplained pain, swelling, vasomotor instability, and
joint stiffness.
■ Type I (previously known as reflex sympathetic dystrophy) occurs secondary
to a noxious event. Type II (also known as causalgia) is caused by direct
peripheral nerve injury.
■ The use of vitamin C for CPRS prophylaxis is controversial, but many still
advocate it given its low side effect profile.
■ Loss of reduction can occur following all forms of distal radius fixation and is
most commonly seen with percutaneous pinning, followed by external fixation
and subsequently internal plating.
■ Internal fixation with plates seems to maintain radiographic parameters better
than other fixation methods.
■ Reoperation is performed in up to 80% of cases in which loss of reduction is
discovered.
■ In particular, lunate facet fractures are prone to loss of reduction.
■ Some surgeons advocate other fixation methods as an adjunct to plating,
such as pins, wires, sutures, or mini-screws.
■ Nonunion after distal radius fixation is rare, with an incidence of less than 1%.
■ If nonunion is experienced, revision is indicated with plate fixation and
autogenous bone grafting.
■ Approximately 65% of patients with intra-articular distal radius fractures go
on to develop radiographic evidence of radiocarpal arthritis, regardless of
treatment modality.
■ Radiographic evidence of radiocarpal arthritis does not seem to correlate with
patient symptoms or functional impairment, however, and functional
outcomes seem to be no different from population norms.
REFERENCES
1. Horst TA, Jupiter JB. Stabilisation of distal radius fractures: lessons learned
and future directions. Injury. 2016;47(2):313-319.
2. Waljee JF, Ladd A, MacDermid JC, et al. A unified approach to outcomes
assessment for distal radius fractures. J Hand Surg [Am]. 2016;41:
565-573.
3. Lee DS, Weikert DR. Complications of distal radius fixation. Orthop Clin
North Am. 2016;47(2):415-424.

24
CHAPTER
Section VI: Rheumatoid
Arthritis
Rheumatoid Arthritis of the
Hand and Wrist
Shoshana W. Ambani and Kevin C. Chung
DEFINITION
■ Rheumatoid arthritis (RA) is a systemic autoimmune disease characterized by
synovial inflammation, which results in progressive joint and soft tissue
destruction that leads to deformity and disability.
PATHOGENESIS
■ RA is an idiopathic disease affecting about 0.5% to 1.0% of the adult
population, with both genetic and environmental factors, which are not fully
understood.
■ For example, there is a three- to fourfold higher frequency in women
compared to men. In addition, patients with the human leukocyte antigen-
antigen D related (HLA-DR) allele have a 4 to 5 increased relative risk of
RA.1
■ Environmental links have also been made, particularly to smoking, caffeine,
silica, and some infectious diseases.
■ On a cellular level, autoreactive T cells and inflammatory cytokines have been
found to play a critical role in the pathogenesis of RA.2,3
■ Tumor necrosis factor (TNF) and interleukin-6 (IL-6), for example, promote
inflammatory cell accumulation, production of matrix metalloproteinases, and
osteoclast activation, which ultimately results in the destruction of cartilage
and bone.

DIAGNOSIS
■ The diagnosis of RA is clinical, based on criteria developed by the American
College of Rheumatology (ACR, previously the American Rheumatism
Association) in 1987 to distinguish RA from other rheumatic diseases (Table
1).4
■ In general, the diagnosis is made by recognizing a pattern of sign and
symptoms, including a history of prolonged morning stiffness that may
improve with activity, polyathralgias, joint swelling, and fatigue.
■ Blood work can help exclude the mimics of RA.
■ Anti–cyclic citrullinated peptide (anti-CCP) antibodies have been shown to
be more than 90% specific for RA.3-5
■ Rheumatoid factor (RF), though not necessary to confirm the diagnosis of
RA, is associated with more severe joint disease and extra-articular
manifestations.
■ Examination findings suggestive of RA include symmetrical polyarthritis and
rheumatoid nodules.
■ Arthrocentesis may be helpful in excluding septic arthritis.
■ Radiographs may be obtained, revealing periarticular osteopenia, joint space
loss, and erosions.
■ In 2010, the ACR/European League Against Rheumatism (EULAR)
developed further criteria for diagnosis in an effort to help identify patients
who would benefit from disease-modifying antirheumatic drugs (DMARDS)
early on before the irreversible effects of RA take place (Table 2).6
DIFFERENTIAL DIAGNOSIS
■ Viral polyarthritis
■ Systemic rheumatic diseases (eg, systemic lupus erythematosus, Sjogren
syndrome, dermatomyositis, mixed connective tissue disease)
■ Palindromic rheumatism
■ Hypermobility syndrome and fibromyalgia
■ Reactive arthritis and arthritis of inflammatory bowel disease
■ Psoriatic arthritis
Table 1 1987 ACR Criteria for Rheumatoid Arthritisa
1. Morning stiffness
• Located in and around joints