Technique Spotlight: Dorsal Plating for Distal Radius Fractures

Indications

Open reduction with internal fixation has become the preferred treatment for most unstable intra-articular and periarticular fractures; however, there is no consensus regarding optimal treatment algorithms and predicted outcomes with various surgical options. Like any fixation technique, each has advantages and disadvantages. Volar locked plating, for example, although popular for most fractures that are dorsally displaced, relies on locking screws to buttress the subchondral bone at the joint. The more the articular surface is compromised, however, the less mechanical advantage these screws have to neutralize the deforming forces. Furthermore, poor bone quality potentially may not allow for enough purchase for screw threads and may allow avulsion of dorsal fragments and consequent loss of reduction. Additionally, the volar approach can lead to greater neuropathic complications or carpal tunnel syndrome from retraction of the median nerve. Dorsal plating has an advantage in these fractures by providing buttress support; however, there are potential complications, notably hardware irritation and extensor tendon–related complications.

Biomechanically, dorsal plating has been shown to be at least equivalent and perhaps superior to volar locking plates in previous investigations. Kandemir et al. demonstrated no difference between volar and dorsal plating in an extra-articular fracture model and in a dorsally comminuted model. Trease et al. found dorsal plates to have a greater rigidity than volar plates and Gondusky et al. noted that dorsal plating resulted in less fracture motion.

The dorsal approach to the distal radius is a reproducible and straightforward approach with no detachment of muscles or mobilization or retraction of significant neurovascular structures. If intra-articular inspection is desired, the visualization afforded by a dorsal approach via a dorsal arthrotomy does so without the need to violate the critical volar wrist ligaments.

Additional advantages of dorsal plate fixation include the ability of more recent plate designs to address more complex fracture patterns than volar plates in isolation, thus minimizing the need for supplemental fragment–specific fixation. An intra-articular fracture with a displaced, far distally fractured radial styloid fragment, for example, may pose a challenge for the one or two screws of a volar plate to secure adequately in order to allow for early motion. Supplemental fixation may be required in addition to the volar plate. Current dorsal plates, on the other hand, extend to the radial styloid by design in a manner in which volar plates cannot. As another example, fragility fractures predictably fracture close to the joint. These far distal fractures are challenging for any fixation technique, but since dorsal plates have the ability to align along the dorsal rim, these plates have the best opportunity to stabilize these fractures.

In summary, the advantages of the dorsal plating techniques for distal radius fractures include (1) the ability to address complex fracture patterns with little need for supplemental fragment–specific fixation; (2) a better option for far distal, fragility fractures; (3) a relatively easier reduction opportunity and a sound, and perhaps superior biomechanical fixation alternative for severely angulated and dorsally comminuted fractures; (4) the ease of dissection without placing major neurovascular structures at risk; (5) the opportunity for hematoma evacuation of the third dorsal compartment and release of the extensor pollicis longus (EPL) tendon from adjacent fracture lines; (6) a relatively less invasive direct visualization of the articular surfaces, if desired; and (7) ability to perform corrective osteotomies, if needed.