Open Reduction and Internal Fixation (ORIF): Dorsal Approach
A longitudinal midline incision is made over the dorsum of the wrist, which provides useful and practical exposure of the dorsum of the radius (Fig. 61—3). The extensor pollicis longus (EPL) is identified distally and traced to the third dorsal compartment. This compartment is often distended from fracture hematoma, and most fractures that split the scaphoid and lunate facets extend into the floor
of the third compartment. This occurs because the stronger and thicker Lister tubercle influences the fracture pattern. The third and fourth compartments are sharply elevated off the dorsal aspect of the capsule, with both the tendon compartments and the dorsal capsular ligaments, including the dorsal radiotriquetral ligament, kept intact. Following this technique avoids the need to repair the extensor retinaculum and related compartments later. Swelling of the tendons and the joint capsule can make closure more difficult. If the dorsal retinaculum is divided and not repaired, the tendons of the fingers and wrist will bow-string with extension of the wrist. The EPL is translocated radially to allow for visualization of the fracture.
The joint capsule is incised transversely and closed later to itself. A longitudinal hand table, traction, and finger-traps provide distraction to the joint and improve the exposure (Fig. 61—4). Dental probes or small Freer elevators can be used to help align the articular fragments and reconstruct the articular surface. It is best to work from the deeper palmar portions of the joint to the more superficial ones. Small 0.035- or 0.045-inch (0.889 or 1.143 mm) Kirschner wires (K wires) are placed to provide support for the reconstruction of the articular surface.
Bone substitute or iliac crest bone graft is placed with K wires for temporary fixation. The radial styloid height is maintained with a 0.062-inch K wire out of the skin and bent to avoid migration. A dorsal plate may be applied, but do not place the tendons out the plate to avoid scarring (Fig. 61—5). Immediate range of motion postoperatively is obtained if the fracture fixation is stable in the operating room.
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