Surgical Management

Discussion was held with the patient regarding risks and benefits of various operative and nonoperative management options. In addition to being concerned about the long-term outcome, the patient was influenced by wanting to continue living independently and requested whatever care would provide the greatest independence in the shortest period of time. The goals of surgical management using a sub-chondral support plate was explained to the patient, who agreed to proceed with surgery. She was brought to surgery 3 days postinjury. After satisfactory anesthesia was obtained, a longitudinal dorsal incision was created between the third and fourth extensor compartments. Dissection was continued subperiosteally in this interval, and the fracture site was exposed and reduced under direct vision. An appro priately sized subchondral dorsal support plate was placed in the standard fashion immediately proximal to the subchondral bone and screwed into the distal radial diaphysis. The patient's bone was notably osteopenic. Screw fixation was felt to be at risk for failure at the bone-screw thread interface.

Therefore, the screw fixation was augmented with polymethyl methacrylate, which provided firm screw fixation. Periosteum was brought over the plate, the interval repaired, and the wound closed in the standard fashion and a bulky short arm splint placed.

Criticism of open reduction and internal fixation (ORIF) of distal radial fractures has often been directed at the size of the incision required, the presence of the implant adjacent to moving tendons, the complexity of the procedure, and the perceived need to remove the implant. In our experience of 60 patients with greater than 2 years' follow-up, however, no patient has had a wound complication, tendinitis, or tendon rupture. The procedure rarely takes more than 90 minutes of tourniquet time and generally less than 45 minutes. Only three of nearly 90 patients have needed or desired implant removal. Although internal plate placement is potentially a new dissection to some surgeons, it is neither difficult to learn nor excessively complex to complete.

The use of pin versus fixator versus plate fixation has long been a topic of controversy. We no longer believe this to be a useful debate. Rather, we believe that future discussions should focus on the relative strength of pin versus fixator versus plate fixation. Prepublication data from our laboratory indicate that loads as high as 300 N are seen at the level of the distal radius during gentle rehabilitation. Therefore, the surgeon must compare the strength of the fixation construct with the planned rehabilitation protocol. A definitive advantage of the plate used in this patient is the plate's ability to resist high load during early fracture consolidation. The most important issue regarding fracture management is the ability of the surgeon to guarantee the patient a high probability of a satisfactory outcome.

This depends on establishing a process that can be accurately repeated. Incision size, dissection difficulty, and fixation type are not the issues of concern except as they relate to the likelihood of consistently replicating a good result. In summary, distal radius fracture care is evolving. The authors have presented a case that they believe emphasizes the need for the surgeon to examine three critical questions: (1) Can the procedure be completed safely? (2) Does the procedure achieve fixation equal to the proposed rehabilitation? (3) Is the fixation-bone interface sufficient? If each question can be satisfactorily answered yes, a successful outcome is almost guaranteed.

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