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 Table of Contents  
SYMPOSIUM - DISTAL RADIAL FRACTURES
Year : 2020  |  Volume : 3  |  Issue : 2  |  Page : 45-48

Distal radius plating: Role and significance


Department of Orthopedics, AIIMS, Raipur, Chhattisgarh, India

Date of Submission27-Jun-2020
Date of Decision15-Jul-2020
Date of Acceptance25-Jul-2020
Date of Web Publication10-Sep-2020

Correspondence Address:
Harshal Sakale
Department of Orthopedics, AIIMS, Raipur, Chhattisgarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JODP.JODP_21_20

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  Abstract 


Distal radius fractures are a very common fracture. They occur mostly due to fall on an outstretched hand. They represent around 17% of all adult fractures. They occur most commonly in young males due to high energy trauma and older females due to osteoporosis. There are various treatment options available for fracture fixation, such as close reduction and manipulation, followed by cast application, close reduction and external fixator application, close reduction with percutaneous K-wire fixation, and open reduction and internal fixation with distal radius plate. Displaced intra-articular fractures are mostly managed with open reduction and distal radius plate fixation. Different fracture patterns require different types of distal radius plates such as T-plate, buttress plate, and variable angle plate. This article outlines the role of plating in distal radius fractures.

Keywords: Distal, fractures, plating, radius


How to cite this article:
Sakale H, Agrawal AC, Verma S, Kar B. Distal radius plating: Role and significance. J Orthop Dis Traumatol 2020;3:45-8

How to cite this URL:
Sakale H, Agrawal AC, Verma S, Kar B. Distal radius plating: Role and significance. J Orthop Dis Traumatol [serial online] 2020 [cited 2020 Oct 31];3:45-8. Available from: https://www.jodt.org/text.asp?2020/3/2/45/294731




  Introduction Top


Many new implant options for fractures of distal radius plating are available. These options are mostly implant and industry driven, with little evidence-based research guiding the way.[1] Currently, several established surgical options are available for displaced distal radius fractures.[1],[2],[3],[4] The choice of surgical technique for reduction and fixation will depend on fracture displacement, joint surface involvement, patient age, bone quality, dominant handedness, occupation, surgeon's experience, patient's preference, etc., which also dictates the treatment method. Unfortunately, a few high-quality literature exists on which to base these treatment decisions.[5]


  Plating Techniques Top


Volar plates and dorsal plates

Dorsal plate placement has a high rate of complications; hence with the advent of new fixed-angle screw-plate designs, volar fixation has become the standard approach for distal radius fractures with joint involvement[6],[7],[8] [Figure 1]. The complications with dorsal plates are stiffness and tendon rupture, etc.[9],[10],[11],[12],[13],[14] The volar plate placement through a flexor carpi radialis approach affords a soft-tissue layer between the skin and the plate that may have greater depth than a dorsal approach.
Figure 1: Dorsal plate

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Volar plates generally fall into the following four functional categories:

  1. Buttress plates with distal screws
  2. Buttress plates without distal screws
  3. Fixed-angled locking plates [Figure 3]
  4. Polyaxial locking plates [Figure 4].[1],[15]


Volar buttress plates are the traditional plate designs used to treat distal radius volar shear fractures and can be used with or without screw fixation in the distal fragment. Because the screws are not locked in the plate construct, they do not resist angular motion effectively. In normal bone or even osteoporotic bone without comminution, a locked device provides no advantage, and a normal buttress plate can be used.
Figure 2: Juxta-articular and extra-articular plate

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Figure 3: Standard and Buttress plate

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Figure 4: Variable and standard locking screws

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Fixed-angle locking plates

Fixed-angle locking plates are implants with screws that lock into the plate at a fixed trajectory. The screw head usually has a thread to engage the corresponding screw hole in the plate. Screws are smooth, give a good subchondral support, and allow direct purchase of bone fragments. Fixed-angled locking plate designs have improved strength characteristics compared with traditional nonlocking plates to resist angular motion. If the locking screws are placed as distal as possible, it will provide subchondral support [Figure 2], and the construct will be more effective at maintaining length.[1]

Polyaxial locking plates

Polyaxial locking plates allow inserting each distal screw with variable angles. They have all the same advantages of fixed-angled locking plates but have the additional advantage of matching the distal fixation to the variable geometry and surface contour of the distal radius [Figure 4]. With polyaxial locking plates, we can address each intra-articular fragment independently. Thus, there is no need to insert a plate in a specific position. They do tend to be thicker and more prominent than the standard locking plate design and differ radically from manufacturer to manufacturer.

Early biomechanical reports show a large variability in the actual rigidity of the plate–screw construct, and the surgeon should become familiar with these reports before deciding on an optimal plate.[1] We believe that the specific plate used might cause complications from dorsal plating, rather than the technique itself, therefore supporting a dorsal approach for dorsally angulated distal radius fractures.

Usually, a volar locking plate, which has fewer complications, is sufficient to manage an intra-articular fracture [Figure 5]. However, in highly comminuted intra-articular fractures, reduction may be achieved indirectly by an external fixation distractor, and then volar locking plate is applied. Loose fragments may be stabilized with temporary K-wires [Figure 6].
Figure 5: Intra-articular fracture fixed with volar locking plate

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Figure 6: Comminuted intra-articular fracture, fixator assisted volar locking plating done, radial styloid fragment fixed with K-wires

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Fragment-specific fixation

Fragment-specific fixation is designed to independently stabilize each major fracture component using an implant specifically designed for each fragment [Figure 7]. Similar to volar locking plates, subchondral support and rigidity can be enhanced. Fragment-specific fixation also takes advantage of increased rigidity provided by implants placed in orthogonal planes.
Figure 7: Fragment-specific implant

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Some manufacturers advocate radial styloid reduction before lunate reduction and fixation for fragment-specific fixation. Most case reports associated with this technique show excellent reduction in short- and medium-term follow-up periods.

The need for anatomic reduction of the lunate may be lost on some surgeons with this technique. The intact lunate fossa articulation is infinitely more useful as a secondary reconstruction platform than the radioscaphoid articulation.[4],[11]

Locking and nonlocking plates

The locking nature of the screw–plate construct produces fixation even in bone defects and osteopenic bone and permits an early range of motion exercises. In contrast to external fixation and percutaneous pinning, no tethering of muscle, tendon, or capsule occurs with plate fixation, and therefore, motion of the wrist and fingers is uninhibited. These advantages would suggest that plate fixation with a volar fixed-angle device should permit earlier and more aggressive rehabilitation and more rapid regain of function when compared with stabilization with external fixation or percutaneous pinning, although this has not been studied systematically. Rapid and effective recovery of function is important in both the young, active population and the elderly population, who often live alone and require both hands to function independently.

Another advantage of a locked plate is the ability to perform indirect reduction.[16] The distal fragment of an A-type fracture, or after fixation of the intra-articular portion of a C-type fracture, may be brought into appropriate palmar tilt through placing the plate off the bone during fixation to the distal piece. Bringing the plate to the bone for proximal fixation performs the indirect reduction as shown in [Figure 8]. A locking plate with a variable angle and multiple screw options and sizes may perhaps help in osteosynthesis of all types of distal radius fractures. Associated fractures of ulnar styloid may be fixed with K-wires [Figure 9].
Figure 8: Appropriate palmar tilt achieved, a) Preoperative X ray, b) Intraoperative Image, c) Postoperative image

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Figure 9: Volar Barton fracture with fracture of ulnar styloid fixed with variable angle volar locking plate and ulnar styloid fixed with K-wire

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  Summary Top


With the capabilities of the operating surgeon, the wide array of options and approaches means that almost all distal radius fractures can be fixed and held in place with open reduction internal fixation Open Reduction Internal Fixation (ORIF). Whether this procedure is required or can reliably be accomplished with the good functional outcome is open to debate until clinically relevant questions are answered by appropriately powered, well-designed studies. Whether plate placement and the newer locking devices have given ORIF, a better outcome for the patients has yet to be determined.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Drobetz H, Bryant AL, Pokorny T, Spitaler R, Leixnering M, Jupiter JB. Volar fixed-angle plating of distal radius extension fractures: Influence of plate position on secondary loss of reduction – A biomechanic study in a cadaveric model. J Hand Surg Am 2006;31:615-22.  Back to cited text no. 1
    
2.
Gradl G, Jupiter JB, Gierer P, Mittlmeier T. Fractures of the distal radius treated with a nonbridging external fixation technique using multiplanar K-wires. J Hand Surg Am 2005;30:960-8.  Back to cited text no. 2
    
3.
Kamath AF, Zurakowski D, Day CS. Low-profile dorsal plating for dorsally angulated distal radius fractures: An outcomes study. J Hand Surg Am 2006;31:1061-7.  Back to cited text no. 3
    
4.
Schnall SB, Kim BJ, Abramo A, Kopylov P. Fixation of distal radius fractures using a fragment-specific system. Clin Orthop Relat Res 2006;445:51-7.  Back to cited text no. 4
    
5.
Handoll HH, Madhok R. Surgical interventions for treating distal radial fractures in adults. Cochrane Database Syst Rev 2003;3:CD003209.  Back to cited text no. 5
    
6.
Rikli DA, Regazzoni P. Fractures of the distal end of the radius treated by internal fixation and early function. A preliminary report of 20 cases. J Bone Joint Surg Br 1996;78:588-92.  Back to cited text no. 6
    
7.
Heim D. Plate osteosynthesis of distal radius fractures--incidence, indications and results. Swiss Surg 2000;6:304-14.  Back to cited text no. 7
    
8.
Hove LM, Nilsen PT, Furnes O, Oulie HE, Solheim E, Mölster AO. Open reduction and internal fixation of displaced intraarticular fractures of the distal radius. 31 patients followed for 3-7 years. Acta Orthop Scand 1997;68:59-63.  Back to cited text no. 8
    
9.
Gliatis JD, Plessas SJ, Davis TR. Outcome of distal radial fractures in young adults. J Hand Surg Br 2000;25:535-43.  Back to cited text no. 9
    
10.
Konrath GA, Bahler S. Open reduction and internal fixation of unstable distal radius fractures: Results using the trimed fixation system. J Orthop Trauma 2002;16:578-85.  Back to cited text no. 10
    
11.
Rikli DA, Regazzoni P. The double plating technique for distal radius fractures. Tech Hand Up Extrem Surg 2000;4:107-14.  Back to cited text no. 11
    
12.
Cohen MS, Turner TM, Urban RM. Effects of implant material and plate design on tendon function and morphology. Clin Orthop Relat Res 2006;445:81-90.  Back to cited text no. 12
    
13.
Lenoble E, Dumontier C, Goutallier D, Apoil A. Fracture of the distal radius. A prospective comparison between trans-styloid and Kapandji fixations. J Bone Joint Surg Br 1995;77:562-7.  Back to cited text no. 13
    
14.
Gruber G, Gruber K, Giessauf C, Clar H, Zacherl M, Fuerst F, et al. Volar plate fixation of AO type C2 and C3 distal radius fractures, a single-center study of 55 patients. J Orthop Trauma 2008;22:467-72.  Back to cited text no. 14
    
15.
Kamano M, Honda Y, Kazuki K, Yasuda M. Palmar plating for dorsally displaced fractures of the distal radius. Clin Orthop Relat Res 2002;397:403-8.  Back to cited text no. 15
    
16.
Prommersberger KJ, van Schoonhoven J, Lanz UB. A radiovolar approach to dorsal malunions of the distal radius. Tech Hand Up Extrem Surg 2000;4:236-43.  Back to cited text no. 16
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]



 

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