Journal of Orthopaedic Surgery 2015;23(1):19-23
Combined volar and dorsal plating for
complex comminuted distal radial fractures
MFM Farhan, JHK Wong, S Sreedharan, FC Yong, LC Teoh
Hand and Microsurgery Section, Department of Orthopaedic Surgery, Tan Tock Seng Hospital, Singapore
ABSTRACT
Purpose. To review outcomes of combined volar
and dorsal locked plating for AO type-C3 complex
comminuted distal radial fractures.
Methods. Records of 24 patients aged 17 to 77
(mean, 53.3) years who underwent combined volar
and dorsal locked plating for AO type-C3 distal
radial fractures with volar and dorsal metaphyseal
and intra-articular comminution were reviewed. 21
were closed fractures, and 3 were Gustilo-Anderson
type-1 open fractures. Bone union, volar tilt, radial
inclination, radial height, range of motion, grip
strength, and any complications were assessed by a
single hand surgeon.
Results. After a mean follow-up of 17 (range, 14–25)
months, the mean palmar flexion was 49º (range,
30º–80º), dorsiflexion was 52º (range, 30º–80º),
supination was 86º (range, 60º–90º), pronation
was 77º (range, 30º–90º), radial deviation was 16º
(range, 5º–30º), and ulnar deviation was 27º (range,
10º–50º). The mean grip strength of the injured hand
was 69.2% of the uninjured side. The mean time to
radiological union was 3.9 (range, 2.5–6.0) months;
no patient had non-union. At the time of union, the
mean volar tilt was 5º (-22º–14º), radial inclination
was 18.6º (8º–28º), and radial height was 8.5 mm (5.0
mm–13.6 mm). One patient had collapse of the dorsal
fragment resulting in a dorsal tilt of 22º and limited
(30º) forearm pronation. The severity of dorsal
metaphyseal comminution had not been recognised
and bone grafting was not performed. The patient
also had minor complications of little finger flexor
tendon irritation and carpal tunnel syndrome. She
underwent implant removal and carpal tunnel
release at 8 months. One patient had implant-related
extensor digitorum communis irritation. Another
patient had non-specific chronic wrist pain, which
was resolved at one year. No patient had infection,
tendon rupture, or complex regional pain syndrome.
Four patients underwent implant removal, including
2 who had no implant-related problems.
Conclusion. Combined volar and dorsal plating
enables early mobilisation and good outcome for
certain complex comminuted distal radial fractures.
Key words: radius fracture; volar plates; wrist joint
Address correspondence and reprint requests to: Dr Sreedharan Sechachalam, Hand and Microsurgery Section, Department of
Orthopaedic Surgery, 11 Jalan Tan Tock Seng, 308433, Singapore. Email: [email protected]
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Journal of Orthopaedic Surgery
MFM Farhan et al.
INTRODUCTION
MATERIALS AND METHODS
Distal radial fractures account for almost 17% of
all fractures in adults.1 Comminuted distal radial
fractures usually occur in elderly people with
osteoporotic bone or in young patients following highenergy trauma.2 AO type-C distal radial fractures3
with volar and dorsal metaphyseal comminution
and intra-articular comminution necessitate surgical
fixation to restore alignment and joint congruity to
avoid limitation in wrist and forearm function.4–7
Volar or dorsal locked plating provides sufficient
stability for early mobilisation, but failure still occurs.
External fixation may collapse, even with additional
Kirschner wires or bone grafting.8 Restriction on
early mobilisation may result in stiffness, and
sub-optimal reduction may result in mal-union.8
Combined internal and external fixation9,10 and wrist
arthrodesis11 have been reported with considerable
morbidity. The ‘sandwich’ osteosynthesis using both
volar and dorsal locked plates provides sufficient
stability for early mobilisation,12–14 but it involves
longer operating time and greater soft-tissue
dissection, which may cause more ischaemia, higher
infection rates, poorer bone healing, and delayed
or non-union. The ‘sandwich’ osteosynthesis is
also associated with tendon irritation or rupture
by the hardware and an increased need for implant
removal.12 This study reviewed outcomes of
combined volar and dorsal locked plating for AO
type-C3 complex comminuted distal radial fractures,
using current lower-profile implants.
Between 2008 and 2009, 24 patients aged 17 to 77
(mean, 53.3) years underwent combined volar
and dorsal locked plating (using Synthes 2.4-mm
locked compression plates [5 were of variable angle,
2-column volar plates]) for AO type-C3 distal radial
fractures with volar and dorsal metaphyseal and
intra-articular comminution (Fig. 1). The mechanism
of injury included fall on an outstretched hand (n=19),
road traffic accident (n=3), and blunt trauma to the
wrist (n=2). 21 were closed fractures, and 3 were
Gustilo-Anderson type-1 open fractures. Patients
with concomitant fractures in the same limb, delayed
fixation requiring osteotomy, secondary surgery
after initial external fixation, or fixation requiring
supplemental external fixation were excluded.
The mean time from injury to surgery was 6 days.
The 21 patients with closed fractures underwent
temporary closed reduction and casting before
surgical fixation. The 3 patients with open fractures
were treated on the day of injury.
Through a single volar approach (Henry
approach), most fractures were reduced by the
direct manual or intrafocal method and stabilised
temporarily using Kirschner wires. The extended
flexor carpi radialis approach15 was used for better
visualisation and approach to the dorsal fragments. To
avoid devascularisation of fragments, periosteum and
soft tissues attached to the fragments were preserved.
The volar plate was fixed first to create a stable volar
cortex for the dorsal fragments. An additional dorsal
(a)
(b)
(c)
Figure 1 Radiographs showing (a) articular comminution and metaphyseal comminution treated with (b) combined volar
and dorsal plating with autologous bone grafting for defect secondary to metaphyseal comminution, and (c) bone union at 4
months, with maintenance of extra-articular parameters and joint congruity.
Vol. 23 No. 1, April 2015
Combined volar and dorsal plating for complex comminuted distal radial fractures
approach may be needed to reduce and stabilise
articular fragments owing to inadequate screws
(rather than inadequate reduction), as the screws in
the volar locking plates may be inadequate to stabilise
small but critical dorso-ulnar fragments and thin
dorsal chondral fragments. The dorsal incision was
centred over the Lister’s tubercle, and the extensor
pollicis longus tendon sheath was divided. The
fracture site was exposed by subperiosteally lifting
off the extensor tendon compartments. Although
this further devascularised the fracture fragments,
it ensured the presence of periosteum between
the implants and the extensor tendons to reduce
the risk of attritional rupture. To prevent further
devascularisation, any disruption to the capsular
attachments was avoided. Dorsal fragments were
reduced and stabilised. Bone grafting was performed
for 8 patients with severe metaphyseal bone loss.
Tension band wiring was performed for 3 patients
with associated ulnar styloid fractures and unstable
distal radioulnar joint after plating. The extensor
pollicis longus tendon was left subcutaneous before
skin closure.
Rehabilitation was started within one week. The
(a)
21
wrist was rested on a volar splint with interval active
range-of-motion exercises monitored by the hand
therapist. This was progressed to passive rangeof-motion exercises at 4 weeks. At 6 to 8 weeks, the
splint was removed and progressive strengthening
exercises started.
Bone union, volar tilt, radial inclination, radial
height, range of motion, grip strength, and any
complications were assessed by a single hand
surgeon.
RESULTS
After a mean follow-up of 17 (range, 14–25) months,
the mean palmar flexion was 49º (range, 30º–80º),
dorsiflexion was 52º (range, 30º–80º), supination
was 86º (range, 60º–90º), pronation was 77º (range,
30º–90º), radial deviation was 16º (range, 5º–30º), and
ulnar deviation was 27º (range, 10º–50º). The mean
grip strength of the injured hand was 69.2% of the
uninjured side. The mean time to radiological union
was 3.9 (range, 2.5–6.0) months; no patient had nonunion. At the time of union, the mean volar tilt was
(b)
Figure 2 Radiographs showing (a) acceptable joint congruity and extra-articular parameters after surgery and (b) collapse of
the dorsal articular surface resulting in excessive dorsal tilt at one month.
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Journal of Orthopaedic Surgery
MFM Farhan et al.
5º (-22º–14º), radial inclination was 18.6º (8º–28º), and
radial height was 8.5 mm (5.0 mm–13.6 mm).
One patient had collapse of the dorsal fragment
resulting in a dorsal tilt of 22º and limited (30º) forearm
pronation (Fig. 2), owing to technical failure and
non-compliance with therapy. Initial postoperative
radiographs showed acceptable joint congruity
restoration and volar tilt. The dorsal plate was used
as a buttress plate with no distal locking screws. The
severity of dorsal metaphyseal comminution had
not been recognised intra-operatively and resulted
in subsidence of the dorsal articular surface. Bone
grafting should have been performed in the dorsal
metaphyseal region, and locking screws should have
been used for purchase of the dorsal subchondral
bone. The patient also had minor complications of
little finger flexor tendon irritation and carpal tunnel
syndrome. She underwent implant removal and
carpal tunnel release at 8 months.
One patient had implant-related extensor
digitorum communis (EDC) irritation, but he
declined implant removal. At 2 years, he still had
mild discomfort over the EDC tendons at the wrist
dorsum, but the tenderness and swelling had resolved
with no rupture of the tendons. Another patient had
non-specific chronic wrist pain, which was resolved
at one year. No patient had infection, tendon rupture,
or complex regional pain syndrome.
Four patients underwent implant removal: one
for fixation failure, one for pain caused by the ulnar
styloid wires (but no pain around the distal radius
implants), and the remaining 2 had no implantrelated problems but requested for implant removal.
DISCUSSION
Combined volar and dorsal plating is needed for
fractures with dorsal articular comminution, dorsal
metaphyseal comminution, and volar comminution.13
In our study, combined plating was also used for
sufficient stabilisation of fragments on the far cortex
owing to inadequate screw purchase from a single
volar or dorsal approach. Combined plating for
distal radial fractures is less necessary since the use
of variable angle locking implants, as the locking
screws can be directed towards a particular fragment
with variable angle plates. Combined plating enables
visualisation of the distal radial articular surface from
the dorsum and bone grafting for the dorsal or volar
metaphysis. In severe metaphyseal comminution,
structural support for the articular surface may be
lacking,8,16 and bone grafting is needed to prevent
subsidence of the distal radial articular surface.
Implant removal is common after combined
volar and dorsal plating for distal radial fractures.12
In our series, only 4 of 24 patients underwent implant
removal. This is attributed to the low-profile plates
used in our study, which also reduce extensor tendon
complications.17,18 There was no infection or nonunion in our series and other series.12,13 This was
due to the excellent vascularity of the distal radius
and preservation of periosteum and soft tissue
attachments to the fracture fragments. Nonetheless,
the mean time to union was 3.9 months, which is
relatively long.
Limitations of this study were the lack of
biomechanical analysis and comparison with single
volar or dorsal plating.
ACKNOWLEDGEMENT
We thank Ms Ong Jing Wen Ivy for her assistance in
data collection and tabulation.
DISCLOSURE
No conflicts of interest were declared by the authors.
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