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Editor: Mark E. Easley
Editor-In-Chief Sam W. Wiesel

Editor: john M. Flynn
Editor-in-Chief Sam W. Wiesel

Editors: Paul Tometta Ill
Gerald R. Williams
Matthew L. Ramsey
Thomas R. Hunt Ill
Editor-in-Chief Sam W. Wiesel

Editors: Gerald R. Williams&: Matthew L. Ramsey
Editor-in-Chief Sam W. Wiesel

Editor: Mark D. Miller
Editor-in-Chief Sam W. Wiesel

Editors: Jarvad Parvizi & Richcwd H. Rothman
Editor-in-Chief Sam W. Wiesel
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Copyright 2011


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Library of Congress Cataloging-in-Publication Data

Operative techniques in hand, wrist, and forearm surgery I Thomas R. Hunt III, editor ; Sam W. Wiesd, editor-in-c:hief.
p.; c:m.
Chapters derived from Operative techniques in orthopaedic: surgery I editor-in-c:hief, Sam Wiesel. c:2010.
Indudes bibliographic:al references and index.
Summary: "Operative Techniques in Hand, Wrist, and Forearm Surgery contains the c:hapters on the hand, wrist, and
forearm from Sam W. Wiesel's Operative Techniques in Orthopaedic: Surgery and provides full-c:olor, step-by-step
explanations of all operative procedures. Written by experts from leading institutions around the world, this superbly
illustrated volume focuses on mastery of operative techniques and also provides a thorough understanding of how to
select the best procedure, how to avoid c:omplic:ations, and what outcomes to expec:t. The user-friendly format is ideal
for quic:k preoperative review of the steps of a procedure. Eac:h procedure is broken down srep by srep, with full-c:olor
intraoperative photographs and drawings that demonstrate how to perform eac:h technique. Extensive use of bulleted
points and tables allows quic:k and easy reference. Eac:h clinical problem is discussed in the same format: definition,
anatomy, physic:al exams, pathogenesis, natural history, physic:al findings, imaging and diagnostic: studies, differential
diagnosis, non-operative management, surgic:al management, pearls and pitfalls, postoperative c:are, outcomes, and
complications. To ensure that the material fully meets residents' needs, the text was reviewed by a Residency Advisory
Board"-Provided by publisher.
ISBN 978-1-4511-0255-0 (hardback)
1. Hand--Surgery. 2. Wrist--Surgery. 3. Forearm-Surgery. I. Hunt, Thomas R. II. Wiesel, Sam W. III. Operative
techniques in orthopaedic: surgery.
[DNLM: 1. Hand--surgery. 2. Forearm--surgery. WE 830 0616 2011]
RD559.064 2011

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10 9 8 7 6 54 3 2 1

To my cherished wife Teri and our four extraordinary children, Thomas, William, Caitlin, and
Christopher, for their love and understanding, and especially for their endless supply of smiles,
laughter, and fun!-TRH

Preface JCVfl 15 Corrective Osteotomy for Distal Radius Malunion
Foreword Jdlc David Ring, Diego Femandez, and Jesse B. Jupiter 1.0
Residency Advisory Board JDd
ANESTHESIA 16 Percutaneous Fixation of
Acute Scaphoid Fractures
1 Anatomy and Surgical Approaches Peter J. L Jebson, JaneS. Tan, and Andrew Wong 152
of the Forearm, wrtst. and Hand
Asif M. 1/yas, Neal C. Chen, and Chaitanya S. Mudgal 1 17 Open Reduction and Internal Fixetion
of Scaphoid Fndures
2 .Anesthetic Considenrtions for Asheesh Bedi and Peter J. L Jebson 15'9
Surgery of the Upper Ex.trernity
John A Dilger and Hugh M. Smith 10 18 Percutaneous Treatment of Grade I to Ill
Scaphoid Nonunlons
3 Arthroscopy of the Hand and Wrist Joseph F. Slade Ill' and Greg Merrell 167
David J. Slutsky 22
19 Volar Wedge Bone Grafting and Internal
Fixation of Scaphoid Nonunlons
20 V&~a~larized Bone Grafting of Avasc:ular
4 Open Reduction ..,d lntemal Fixation of Scaphoid Nonunion•
Diaphyseal Forearm Fractures Alexander D. Mih 1r1
Michael R. Boland 35 21 Partial Scaphoid Excision of
5 Reduction and Stabilization of the Distal Scaphoid Nonunlons
Radioulnar Joint Following Galeazzl Fractures Joseph E. lmbriglia and Justin M. Sacks 185
Michael R. Boland 47 22 Surgical Treatment of C'arpal Bone
6 ComadiYe Osteotomy for Radius and Ulna Fractures, Excluding the Scaphoid
Diaphyseal Malunion• Kenneth R. Means. Jr. and Thomas J. Graham 1.12
Vimala Ramachandran and Thomas F. Varecka 57 23 Osteotomy of the Radius for
7 Operative Treatment of Radius and Ulna Treatment of Kienbac:k. Di.....
Diaphyseal Nonunlons Jeffrey E. Budoff 2fB
Rena L Stewart 61 24 Vascularized Bone Grafting and
8 K-Wire Fixation of Distal Radius Fractures capitate Shortening Osteotomy
With and Without Extemal Fixation for Treatment of Klenbac:k. Disease
Christopher Doumas and David J. Bozentka 70 Nilesh M. Chaudhari, Mohamed Khalid,
and Thomas R. Hunt Ill :ns
9 Arthroscopic Reduction ..,d Fixation of
Distal Radius and Ulnar Styloid Fractures
10 Fragment-SpecHic Fixation
of Distal Radius Fractures 2S Ligament Stabilization of the Unstable
Robert J. Medoff 9f 'lhumb carpometacarpal Joint
11 Intramedullary and Dorsal Plate Fixation Richard Y. Kim and Robert J. Stl'auch 221
of Distal Radius Fractures 26 Operative Treatment of 'lbumb
Pedro K. Beredjiklian and Christopher Doumas 106 C'Mpometacarpal Joint Fractures
12 Volar Plating of Distal Radius Fractures John T. Capo and Colin Harris 228
John J. Fernandez 114 27 Dislocations and Chronic Volar Instability of
13 Bridge Plating of Distal Radius Frac:tures the 'lhumb Metacarpophalangeal Joint
Paul A Martineau, Kevin J. Malone, Robert R. Slater, Jr. Z3fJ
and Douglas P. Hanel 126 28 Arthroscopic and Open Primary Repair of Acute
14 Open Reduction and Internal Fixation 'lhumb Metacarpophalangeal Joint Radial and
of Ulnar Sf:Jioid, Head, ..,d Ulnar Collateral Ligament Disruptions
Metadiaphyseal Fractures Alejandro Badia and Prakash Khanchandani 250
Tommy Lindau and Andrew J. Logan 1.12 tdeceased

29 Reconstnlction of Chronic Radial 46 Reduction and Association of the Scaphoid and

and Ulnar Instability of the Thumb the Lunate for Scapholunate Instability
Metacarpophalangeal Joint Richard Y. Kim and Melvin P. Rosenwasser 4m
Steven Z. G/ickel and Louis W. Catalano Ill 257 47 Lunotriquetral Ligament Repair
30 Operative Treatment of Finger Carpometacarpal and Augmentation
Joint Fracture-Dislocations Samuel C. Hoxie and Alexander Y. Shin «19
John J. Walsh IV 266 48 Operative Treatment of Lesser
31 Operative Treatment of Metacarpal Fractures and Greater Arc Injuries
Christopher L. Forthman and Thomas J. Graham 273 Leonard L. D'Addesi, Joseph J. Thoder,
and Kristofer S. Matullo 421
32 Operative Treatment of Extra-articular
Phalangeal Fractures 49 Arthroscopic and Open Triangular
Timothy W. Harman, Thomas J. Graham, Fibrocartilage Complex Repair
and Richard L Uhl 286 A. Lee Osterman 428
33 Open Reduction and Internal Fixation of 50 Intra-articular Radioulnar Ligament
Phalangeal Condylar Fractures Reconstnlction
Greg Merrell Kerry Bemers. and Arnold-Peter Weiss 300 Brian D. Adams and Christina M. Ward 436
34 Dorsal Block Pinning of Proximal 51 Extra-articular Reconstructive Techniques for
Interphalangeal Joint Fracture-Dislocations the Distal Radioulnar and Ulnocarpal Joints
Mark Goleski and Jeffrey Lawton 312 Christopher J. Dy, E. Anne Ouellette.
35 Dynamic External Fixation of Proximal and Anna-Lena Makowski 443
Interphalangeal Joint Fracture-Dislocations 52 Arthroscopic Dorsal Radiocarpal Ligament Repair
Grey Giddins 318 David J. Slutsky 452
36 Open Reduction and Internal Fixation
of Proximal Interphalangeal SECTION VI TENDON INJURIES AND
Joint Fracture-Dislocations DISORDERS
Brian Najarian and Jeffrey Lawton 328
53 Distal Biceps Tendon Disruptions: Acute
37 Volar Plate Arthroplasty and Delayed Reconstruction
Albert Leung and Philip E. Blazar 339 Robert E. Ivy and Edwin E. Spencer, Jr. 458
38 Hemi-Hamate Autograft Reconstruction 54 Repair of Acute Digital Flexor Tendon
of Unstable Dorsal Proximal Interphalangeal Disruptions
Joint Fracture-Dislocations Christopher H. Allan 40
Thomas R. Kiefhaber, Rafael M. M. Wil/iams.
and Soma I. Ully 344 55 Tenolysis Following Injury and Repair of
Digital Flexor Tendons
39 Operative Treatment of Distal Interphalangeal Shai Luria and Christopher H. Allan 469
Joint Fracture-Dislocations
Leo T. Kroonen and Eric P. Hofmeister 353 56 Staged Digital Flexor Tendon Reconstruction
Kevin J. Malone and Thomas Trumble 478
40 Corrective Osteotomy for Metacarpal and
Phalangeal Malunion 57 Repair Following Traumatic Extensor Tendon
Mohamed Khalid, Nilesh M. Chaudhari, Disruption in the Hand. Wrist, and Forearm
and Thomas R. Hunt Ill 360 David B. Shapiro and Mark A. Krahe 4115
58 Tendon Transfer and Grafting for
Traumatic Extensor Tendon Disruption
SECTION V WRIST INSTABILITIES John S. Taras and Daniel J. Lee 495

41 Arthroscopic Evaluation and Treatment 59 Extensor Tendon Centralization

of Scapholunate and Lunotriquetral Following Traumatic Subluxation
Ligament Disruptions at the Metacarpophalangeal Joint
Alexander H. Payatakes. Alex M. Meyers, Ross J. Richer, Craig S. Phil/ips. and Leon S. Benson 502
and Dean G. Sotereanos 367 60 Flexor and Extensor Tenosynovectomy
42 Open Scapholunate Ligament Repair Jay T. Bridgeman and Sanjiv Naidu Sff
and Augmentation 61 Tendon Transfers Used for Treatment
Alex M. Meyers, Alexander H. Payatakes, of Rheumatoid Disorders
and Dean G. Sotereanos 375 John D. Lubahn and D. Patrick Wil/iams 516
43 Capsulodesis for Treatment of 62 Operative Reconstruction of Boutonni6re
Scapholunate Instability and Swan-Neck Deformities
Angel Ferreres, Marc Garcia-Elias. and Andrew Chin 3BO Mark Wilczynski, Martin I. Boyer,
and Fraser J. Leversedge S27
44 Tenodesis for Treatment of
Scapholunate Instability 63 Open Treatment of Medial Epicondylitis
Marc Garcia-Elias and Angel Ferreres 388 Joseph E. Robison and Peter J. Evans 542
45 Bone-Ligament-Bone Reconstruction 64 Open and Arthroscopic Treatment of
of the Scapholunate Ligament Lateral Epicondylitis
Anthony M. DeLuise, Jr. and Randall W. Culp 396 Peter J. Evans 546

65 Surgical Trea'bnent for Extensor carpi 82 Thumb carpometacarpal Joint Arthrodesis

Ulnaris Subluxation Warren C. Hammett and Matthew M. Tomaino 678
David H. MacDonald and Thomas R. Hunt Ill 5Sf 83 Thumb Carpometacarpal Joint
66 A1 Pulley Release for Trigger Finger With Resedion Arthroplasty
and Without Flexor Digitorum Superficialis Matthew M. Tomaino 684
Ulnar Slip Excision 84 Thumb carpometacarpal Joint Implant
Alexander M. Marcus 5S8 and Resurfacing Arthroplasty
Matthew J. Rabon and Matthew M. Tomaino 6.92
INJURY Carlos Heras-Palou 699

67 Carpal Tunnel Release: Endoscopic, Open, 86 Open and Arthroscopic Radial Styloidectomy
and Revision Bruce A. Monaghan 103
Edward Diao 565 87 Proximal Row Carpectomy
Alex M. Meyers, Mark E. Baratz, and Thomas Hughes 710
68 Decompression of Pronator and Anterior
Interosseous Syndromes 88 Limited Wrist Arthrodesis
E. Bruce Toby and Kyle P. Ritter 574 Andrew W. Cross and Mark E. Baratz 716
69 Decompression of the Ulnar Nerve at 89 Complete Wrist Arthrodesis
Guyon's Canal John C. Elfar and Andrew D. Markiewitz 725
Harris Gellman and Patrick Owens 579 90 Wrist Implant Arthroplasty
70 Surgical Trea'bnent of Cubital Joel C. Klena, Andrew K. Palmer,
Tunnel Syndrome and James W. Strickland 730
Catherine M. Curtin and AmyL. Ladd 5BS 91 Resedion Arthroplasty of the
71 Radial Nerve Decompression Distal Radioulnar Joint
Mark N. Awantang, Joseph M. Sherrill, Christopher J. Jeffrey A Greenberg 739
Thomson, and Thomas R. Hunt Ill 5!0
92 Sauv,·Kapandji Procedure for
72 Primary Repair and Nerve Grafting Distal Radioulnar Joint Arthritis
Following Complete Nerve Transection Robert M. Szabo 74B
in the Hand, Wrist. and Forearm 93 Ulnar Head Implant Arthroplasty
Randy R. Bindra and Jeff W. Johnson .59.9
Cari Cordell and Randy R. Bindra 757
73 Surgical Trea'bnent of Nerve Injuries 94 Arthroscopically Assisted Triangular
in Continuity Fibrocartilage Complex D6bridement
Randy R. Bindra and Jeff W. Johnson 607 and Ulnar Shortening
74 Tendon Transfers for Median Nerve Palsy Daniel J. Nagle 76S
Jeffrey B. Friedrich and Scott H. Kozin 614 95 Ulnar Shortening Osteotomy
75 Tendon Transfers for Ulnar Nerve Palsy Lance G. Warhold and Nelson L. Jenkins 772
Michael S. Bednar 623
76 Tendon Transfers for Radial Nerve Palsy SECTION IX VASCULAR DISORDERS,
SECTION VIII ARTHRITIS 96 Surgical Decompression of the Forearm, Hand,
77 Metacarpophalangeal Joint Synovectomy and and Digits for Compartment Syndrome
Extensor Tendon Centralization in the Marci D. Jones. Rodrigo Santamarina,
Inflammatory Arthritis Patient and Lance G. Warhold 783
Andrew L. Terrano, Paul Feldon, 97 Surgical Treatment of lnjedion
and Hervey L. Kimball Ill 637 Injuries in the Hand
78 Proximal Interphalangeal and Rimma Finkel, Emese Kalnoki-Kis.
Metacarpophalangeal Joint Silicone and Morton Kasdan 790
Implant Arthroplasty 98 Revascularization and
Charles A Goldfarb 6f4 Replantation of the Digits
Marc Richard, R. Gordon Lewis, Jrv and L. Scott Levin 796
79 Proximal Interphalangeal and
Metacarpophalangeal Joint Surface 99 Surgical Treatment of Vasospastic and
Replacement Arthroplasty Vasa-occlusive Diseases of the Hand
Peter M. Murray and Christopher R. Go/1 652 Scott L. Hansen, Neil F. Jones, and Charles K. Lee 801
80 Distal Interphalangeal. Proximal 100 Surgical Treatment of Acute and
Interphalangeal, and Metacarpophalangeal Chronic Paronychia and Felons
Joint Arthrodesis Eric Stuffmann and Jeffrey Yao Bf4
Charles Cassidy and Jennifer Green 660 101 Surgical Treatment of Deep Space
81 Thumb Metacarpal Extension Osteotomy Infections of the Hand
Matthew M. Tomaino 674 Eric Stuffmann and Jeffrey Yao 820

102 Surgical Treatment of Septic Arthritis 112 Open and Arthroscopic Excision of
in the Hand and Wrist Ganglion Cysts and Related Tumors
kif M. 1/yas B2S Mitchell E. Nahra and John S. Bucchieri 918
113 Surgical Treatment of Nerve Tumors
SECTION X SOFT TISSUE LOSS, THERMAL in the Distal Upper Extremity
INJURIES, AND CONTRACTURE$ Christopher L. Forthman and Philip E. Blazar .!DO
114 Treatment of Enchondroma. Bone cyst
103 Nail Matrix Repair. Reconstruction. and Giant Cell Tumor of the Distal
and Ablation Upper Extremity
Reuben A Bueno, Jr. and Elvin G. Zook 812 Edward A Athanasian 937
104 Soft Tissue Coverage of Fingertip
Christian Ford and Jeffrey Yao 840
105 Skin Grafts and Skin Graft Substitutes
in the Distal Upper Extremity 115 Release of Simple Syndactyly
James N. Long, Jorge de Ia Torre, DonaldS. Bae 94S
and Luis 0. Vasconez 849 116 Correction of Thumb-in-Palm Deformity
106 Rotational and Pedicle Flaps for Coverage in Cerebral Palsy
of Distal Upper Exb'emity Injuries Thanapong Waitayawinyu and Scott N. Oishi 9S2
R. Gordon Lewis, Jr., Marc Richard, and L Scott Levin BSB
117 Release of the A1 Pulley to Correct
107 Surgical Treatment of Thermal and Congenital Trigger Thumb
Electrical Injury and Contracture Involving Roger Cornwall 960
the Distal Upper Extremity 118 Transfer of Flexor carpi Ulnaris
Edwin Y.. Chang and Kevin C. Chung 869 for Wrist Flexion Deformity
108 Release of Posttraumatic Ann E. Van Heest 96S
Metacarpophalangeal and Proximal 119 Radial Dysplasia Reconstruction
Interphalangeal Joint Contractures Scott N. Oishi and Marybeth Ezaki 970
Christopher L. Forthman and Keith A Segalman BBO
120 Forearm Osteotomy for MuHiple
109 Surgical Treatment of Dupuytren's Disease Hereditary Exostoses
Ghazi Rayan 891 Carla Baldrighi and Scott N. Oishi 974

110 Surgical Treatment of Vascular EXAM TABLE 1
Tumors of the Hand
Rimma Finkel and Morton Kasdan 900
111 Excision and Coverage of Squamous Cell
carcinoma and Melanoma of the Hand
Mark F. Hendrickson and Benjamin J. Boudreaux 912


I ------------------------------------------------------------~

Brian D. Adamt, MD Leon S. Ben1t011, MD Reuben A. Bueno, Jr., MD

Profe.or of Orthopedic Surgery and Professor of Clinical Orthopaedic Surgery Assistant Professor of Plaetic Surgery
Bioengineering University of Chicago Pritlker School of Southern Dlinnis University School of
University of Iowa Medicine Medicine
Iowa City, Iowa nlinois Bone and Joint In.titute Springfield, Dlinnis
Glenview, nlinois
Chrittopher H. A1lao. MD John T. Capo, MD
Associate Profe11or of Orthopaedia and Pedro K. Beredjiklian, MD Associate Professor of Orthopaedics
Sport. Medicine Aseociate Professor of Orthopaedic Surgery Chief, Division of Hand and Microvascular
University of Waehington Thomas Jefferson School of Medicine Surgery
Seattle, Washington Chief, Hand Surgery Division UMDNJ-New Jersey Medical School
Edward A. Athanasim, MD The Rothman Institute Newark, New Jersey
Associate Profe11or of Clinical Thomas Jefferson School of Medicine
Philadelphia, Penn.ylvania Charles Cassidy, MD
Orthopaedic Surgery Henry H. Banks Associate Professor and
Weill Cornell Medical College Raoc:ly R. Bindra, MD Chairman
Associate Attendmg Orthopaedic Surgeon Professor of Orthopaedic Surgery Tufts University School of Medicine
Hospital for Special Surgery Loyola University Medical Center Orthopaedist in Chief at Tufts Medical
New York, New York Maywood, nlinois Center
Mark N. Awantana. MD Bolton, Massachusetts
Philip E. Bloar, MD
Orthopedic A11ociatee
Wa~n, Diruict of Columbia
Aaistant Professor of Orthopedic Surgery Louis W. Catalano m, MD
Brigham and Women's Hospital Assistant Clinical Professor
Alejandro Badia, MD, FAa; Boston, Columbia University
Badia Hand to Sboulder Center
Mic:hael R. Boland, MBChB, FROi,
c. v. Staff
Chid' of Hand Surgery Hand Surgery Center
Baptist Ho.spital FRAOi Roosevelt Hospital
Assistant Professor of Orthopaedic Surgery New York, New York
Miami, Florida
University of Kentucky College of
Donald S. Bae, MD Medicine Edwin Y. Chaq, MD
AasiataDt Profe11or Lex:illgton, Kentucky Spokane Plaltic Surgeons
Department of Orthopaedic Surgery Spokane, Washington
Harvard Medical School Benjamin J. Boudreaux, MD
Children's Hoepital Bolton Aaistant Clinical Profaeor of Plastic Nilem M. Chaadhari, MD
Bolton, Ma11achueetts Surgery Assistant Professor of Surgery
Louisiana State University Department of Orthopaedic Surgery
Carla BaldriiJhi, MD Baton Rouge, Louisiana University of Alabama, Binningham
Department of Birmingham, Alabama
Microsurgery Martin L Boyer, MD
Ospedale cro Carole B. and Jerome T. Loeb Profc11or of Neal C. Chen, MD
Azienda Ospedaliero-Universitaria Careggi Orthopaedic Surgery Clinical Instructor
Florence, Italy Department of Orthopaedic Surgery Department of Orthopaedic Surgery
Washi.ogton University School of Medicine University of Michigan
Mark E. Baratx, MD St. Louis, Missouri Ann Arbor, Michigan
Profe.or and Executive Vice Chairman
Chid', Upper Extremity Service David J. Bozentka, MD Andrew Olin, MD FROi
Director of Orthopaedic Reeidenq and Aseociate Professor of Orthopaedic Surgery Consultant Hand Surgeon
Upper Extremity Fellowship University of Pennsylvania Hand Surgery Unit
Department of Orthopaedic Surgery Chief, Orthopaedic Surgery Singapore General Hospital
Drexel University College of Medicine Penn Presbyterian Medical Center Singapore
Allegheny General Hospital Philadelphia, Penn.ylvania
Pitt1burgb, Penneylvania Kevin C. Ch11118f MD, MS
Jay T. Bridgeman, MD Profe11or of Surgery
A•hee.h Bedi, MD Assistant Professor of Orthopaedic• Section of Plastic Surgery
Aasiatant Professor of Orthopaedic Surgery Penn State Herahey .Bolle and Joint University of Michigan
University of Michigan Healtb System IDstitute Ann Arbor, Michigan
Ann Arbor, Michigan Hershey, Pennsylvania
Evan D. CollinJ, MD
Michael S. Bednar, MD JohnS.Bucclrieri,MD Assistant Professor of Orthopaedics
Profe110r of Orthopaedic Surgery Private ~ce, Lake Health Weill Cornell Medical College
and Rdlabilitation Willoughby, Ohio New York, New York
SUitch School of Medicine Staff Physician
Loyola University--Chic:qo Jeffrey E. Budoff, MD Department of Orthopaedics
Maywood, Dlinoie Director, Orthopaedic Hand and Upper The Methodist Hospital
Extremity Service Houston, Texas
Kerry Bemen, CRT Houston VA Medical Center
University Orthopeditl Southwest Orthopaedic Group
Providence, Rhode bland Houston, Texas


Carl Cocdell, MD Peter J. Evans, MD, PhD, FRCSC Grey Giddins, MBB<ll, FRCS(Orth), EDHS
Fellow Director, Hand and Upper Extremity Consultant Orthopaedic and Hand
Department of Orthopaedics Department of Orthopaedics Surgeon
Loyola University Medical Center Cleveland Clinic Department of Orthopaedics
Maywood, Illinois Cleveland. Ohio Royal United Hospital
Bath, England
Roger Cornwall, MD Marybeth Ezalri, MD
Assistant Professor of Orthopaedic Surgery Professor of Orthopaedic Surgery Steven z. Glickel, MD
University of Cincinnati College of Department of Hand Service Clinic:al Professor of Orthopaedic Surgery
Medicine Texas Scottish Rite Hospital for Children C. V. Staff
Cincinnati, Ohio Dallas, Texas Hand Surgery Center
Roosevelt Hospital
Andrew W. Cross, DVM, MD Paul Feldon, MD New York, New York
Hand Surgery Specialists, Inc. Clinical Associate Professor of Orthopaedics
Cincinnati, Ohio Tufts University School of Medicine Charles A. Goldfarb, MD
New England Baptist Hospital Associate Professor
Randall W. Culp, MD Boston, Massachusetts Department of Orthopaedic Surgery
Professor of Orthopaedic Hand and Washington University School of Medicice
Microsurgery Diego Fernandez, MD
St. Louis, Missouri
Department of Orthopaedics Lindenhof Hospital
Thomas Jefferson University Hospital Bern, Switzerland Mark Goleski, MD
Philadelphia, Pennsylvania Resident of Internal Medicine
JohnJ. Fernandez, MD UT Southwestern Medical Center
Catherine M. Curtin, MD Assistant Professor of Orthopaedic Surgery
Dallas, Texas
Assistant Professor of Plastic Surgery Division of Hand, Wrist, and Elbow
Stanford University Rush University Medical Center Christopher R. Goll, MD
Pal Alto, California Chicago, Dlinois Heekin Orthopaedics
jacksonville, Florida
Leonard L. D'Addesi, MD Angel Ferreres, MD, PhD
Orthopaedic Associates of Reading Consultant Hand Surgeon Thomas J. Graham, MD
Reading Hospital and Medical Center Hand Surgery Unit Associate Professor
West Reading, Pennsylvania Institut Kaplan Department of Orthopaedic Surgery
Barcelona, Spain Department of Plastic Surgery
Jorge de Ia Torre, MD 1ohns Hopkins School of Medicine
Professor of Surgery Rimma Finkel, MD
Chief, Plastic Surgery Chandler, Arizona Chief, The Curtis National Hand Center
Vice-Chair, Department of Orthopaedic
Division of Plastic Surgery Surgery
Department of Surgery Christian Ford, MD
Chief Resident Director, MedStar SportsHealth
University of Alabama at Birmingham
Department of Plastic Surgery Founder and Surgeon-in-Chief, Arnold
Birmingham VA Medical Center Palmer SportsHealth Center
Birmingham, Alabama Stanford Hospitals and Clinics
Palo Alto, California Union Memorial Hospital
Anthony M. DeLuise, Jr., MD Baltimore, Maryland
Fellow Christopher L. Forthman, MD
Consultant, Curtis National Hand Center Jennifer Green, MD
Department of Orthopaedic Surgery Hand and Upper Extremity Surgeon
Thomas Jefferson University Hospital Department of Orthopaedic Surgery
Philadelphia, Pennsylvania Union Memorial Hospital Newton Wellesley Orthopaedic Association
Baltimore, Maryland Newton, Massachusetts
Edward Diao, MD
Jeffrey B. Friedrich, MD Jeffrey A. Greenberg, MD, MS
Professor Emeritus of Orthopaedic Surgery Clinic:al Assistant Professor
and Neurosurgery Assistant Professor of Surgery and
University of California, San Francisco Orthopedics (Adjunct) Department of Orthopedics
University of Washington Indiana University
San Francisco, California Indiana Hand Center
Seattle, Washington
John A. Dilger, MD Indianapolis, Indiana
Department of Anesthesiology Marc Garcia-Elias, MD, PhD
Consultant Hand Surgeon Warren C. Ham.m.ert, MD
Mayo Clinic:
Hand Surgery Unit Associate Professor of Orthopaedic Surgery
Rochester, Minnesota and Plastic Surgery
lnstitut Kaplan
Christopher Doumas, MD Barcelona, Spain Department of Orthopaedic Surgery and
Clinic:al Assistant Professor of Orthopaedic Rehabilitation
Surgery William B. Geissler, MD University of Rochester Medical Center
Robert Wood Johnson Medical School Professor and Chief Rochester, New York
University of Medicine and Dentistry of Division of Hand and Upper Extremity
Surgery Douglas P. Hanel, MD
New Jersey Professor of Orthopaedics and Sports
New Brunswick, New Jersey Chief
Arthroscopic Surgery and Sports Medicine Medicine
Christopher J. Dy, MD, MSPH Department of Orthopaedic Surgery and University of Washington
Resident Physician Rehabilitation Head, Pediatric Hand Surgery Program
Department of Orthopaedic Surgery University of Mississippi Medical Center Children's Hospital Medical Center
Hospital for Special Surgery Jackson, Mississippi Seattle, Washington
New York, New York Scott L. Hansen, MD
Harris Gellman, MD
John C. Elfar, MD Voluntary Professor Assistant Professor of Surgery
Assistant Professor Department of Orthopedic and Plastic Division of Plastic and Reconstructive
Department of Orthopaedics Surgery Surgery
University of Rochester University of Miami University of California, San Francisco
Rochester, New York Miami, Florida San Francisco, California

Timothy W. Harman, BA, DO Peter J. L. Jebson, MD Hervey L. Kimball III, MD

Associate Clinical Professor Assoc:iate Professor Clinical Instructor of Orthopaedics
Assistant Program Director Chief, Division of Elbow and Hand Surgery Tufts University School of Medicine
Department of Orthopedics Department of Orthopaedic: Surgery New England Baptist Hospital
Ohio University University of Mic:higan Health System Boston, Massachusetts
Dayton, Ohio Arm Arbor, Michigan
Joel C. Klena, MD
Colin Harris, MD Nelson L jenkins, MD Director of Hand Division
Department of Orthopaedics Hand Surgery Fellow Department of Orthopaedic: Surgery
UMDNJ-New Jersey Medic:al School Department of Orthopedics Geisinger Medical Center
Newark, New Jersey University of Massachusetts Danville, Pennsylvania
Worcester, Massachusetts
Mark F. Hendrickson, MD Scott lL Kozin, MD
Section Head, Hand Surgery JeffW.Johnson, MD Professor of Orthopaedic: Surgery
Cleveland Clinic: Adjunct Assistant Oinic:al Professor Temple University School of Medicine
Cleveland, Ohio Department of Orthopaedic: Surgery Hand Surgeon
University of Arkansas for Medical Scienc:es Shriners Hospital for Children
Carlos Heras-Palou, MD, Ozark Orthopaedic: Associates Philadelphia, Pennsylvania
FRCS(Trau&Orth) Fayetteville, Arkansas
Pulvertaft Hand Centre Mark A. Krahe, DO
Royal Derby Hospital Marci D. Jones, MD Professor of Orthopaedic Surgery
Derby, England Assoc:iate Professor Hamot Hospital
Department of Orthopedic: Surgery and Erie, Pennsylvania
Eric P. Hofmeister, MD Rehabilitation
Assistant Professor of Surgery Department of Cell Biology Leo T. Kroonen, MD
Uniformed Services University of the University of Massachusetts Staff Surgeon
Health Sciences Worcester, Massachusetts Division of Hand and Microvascular
Vice Chairman and Director, Hand and Surgery
Microvascular Servic:e Neil F. Jones, MD Department of Orthopaedic: Surgery
Department of Orthopaedic: Surgery Professor of Orthopaedic: Surgery Naval Medic:al Center, San Diego
Naval Medical Center, San Diego Chief of Hand Surgery San Diego, California
San Diego, California University of California
Irvine Medic:al Cenrer AmyL. Ladd, MD
Samuel C. Hoxie, MD Orange, California Professor of Orthopaedic Surgery
Department of Orthopaedic: Surgery Chief, Chase Hand & Upper limb Center
Mayo Clinic: Jesse B. Jupiter, MD Stanford University School of Medicine
Rochester, Minnesota Hanstorg Wyss/AO Professor of Chief of the Children's Hand Clinic:
Orthopaedic: Surgery Lucile Packard Children's Hospital
Harry A. Hoyen, MD Harvard Medical School Palo Alto, California
Assistant Professor of Orthopaedic Surgery Chief, Hand and Upper limb Service
Case Western Reserve University Massachusetts General Hospital Jeffrey Lawton, MD
MetroHealth Medical Center Boston, Massachusetts Hand and Upper Extremity Surgeon
Cleveland, Ohio Department of Orthopaedic: Surgery
Emese Kalnoki-Kis, MD Cleveland Clinic Foundation
Thomas Hughes, MD Resident, Plastic: Surgery Cleveland, Ohio
Assistant Professor Phoenix Integrated Surgic:al Residency
Department of Orthopaedic: Surgery Phoenix, Arizona Charles K. Lee, MD
Drexel University College of Medic:ine Assistant Clinical Professor of Surgery
Philadelphia, Pennsylvania Morton Kasdan, BA, MD Department of Plastic and Reconstructive
Allegheny General Hospital Clinical Professor Surgery
Pittsburgh, Pennsylvania Division of Plastic: Surgery University of California, San Francisco
University of Louisville San Francisco, California
Thomas R. Hunt HI, MD Louisville, Kentucky
Professor of Surgery Danielj. Lee, MD
John D. Sherrill Endowed Chair of Mohamed Khalid, MD Department of Orthopaedic: Surgery
Orthopaedic: Surgery Fellow, UAB Hand and Upper Extemity Pomona Valley Hospital Medic:al Cenrer
Director, UAB Hand and Upper Extremity Fellowship Southern California Orthopaedic Center
Fellowship Department of Orthopaedic: Surgery Pomona, California
Surgeon-in-Chief, UAB Highlands Hospital University of Alabama, Birmingham
University of Alabama School of Medicine Birmingham, Alabama Albert Leung, MD
Birmingham, Alabama Brigham and Women's Hospital
Prakash Khanchandani, MD Boston, Massachusetts
Asif M. Ilyas, MD Hand Fellow
Direc:tor, Temple Hand Center Miami Hand Center Fraser J. Leversedge, MD
Assistant Professor Miami, Florida Assistant Professor
Department of Orthopaedic: Surgery Division of Orthopaedic: Surgery
Temple University Hospital Thomas R. Kiefhaber, MD Duke University
Philadelphia, Pennsylvania Hand Surgery Specialists Durham, North Carolina
Cinc:innati, Ohio
Joseph E. Imbriglia, MD L. Soon Levin, MD, FACS
Clinic:al Professor Richard Y. Kim, MD Chair of Orthopaedic: Surgery
Department of Orthopaedic: Surgery Director of Hand Surgery University of Pennsylvania School of
University of Pittsburgh Medical Center Departments of Plastic: & Reconstructive Medicine
Pittsburgh, Pennsylvania Surgery and Orthopaedic: Surgery Philadelphia, Pennsylvania
Hackensack University Medical Center
Robert E. Ivy, MD Hackensack, New Jersey
Knoxville, Tennessee

R. Gordon Lewis, Jr., MD Paul A. Martineau, MD, FRCSC Scott N. Oishi, MD

Private Practice Assistant Professor Assistant Professor of Plastic: Surgery
Department of Plastic Surgery Section of Sport Medicine Department of Hand Service
CJW Hospital Section of Upper Extremity Surgery Texas Scottish Rite Hospital for Children
Ric:hmond, Virginia Department of Orthopaedic: Surgery Dallas, Texas
McGill University Health Center
Soma L Lilly, MD Montreal, Quebec, Canada A. Lee Osterman, MD
Orthopaedic and Neurosurgical Center of Professor
the Cascades Kristofer S. Matullo, MD Hand and Orthopedic: Surgeon
Bend, Oregon Department of Orthopaedic: Surgery Thomas Jefferson University
St. Luke's Hospital The Philadelphia Hand Center
Tommy Lindau, MD, PhD Bethlehem, Pennsylvania King of Prussia, Pennsylvania
Assistant Professor in Hand Surgery
The Pulvertaft Hand Unit Kenneth R. Means, Jr., MD E. Anne Ouellette, MD, MBA
Royal Derby Hospital Attending Surgeon Miami International Hand Surgical
Derby, United Kingdom Curtis National Hand Center Services
Union Memorial Hospital North Miami Beach, Florida
Andrew J. Logan, MB, BCh Baltimore, Maryland
Department of Orthopaedics Patrick Owens, MD
University Hospital of Wales Robert}. Medoff, MD Assistant Professor of Clinical
Cardiff, Wales Windward Orthopedic Group Orthopaedics
Kailua, Hawaii Hand and Upper Extremity Surgery
James N. Long, MD University of Miami Leonard M. School of
Assistant Professor Greg Merrell, MD Medicine
Department of Plastic: and Reconstructive Indiana Hand to Shoulder Center Miami, Florida
Surgery Indianapolis, Indiana
University of Alabama at Birmingham Andrew K. Palmer, MD
Birmingham, Alabama Alex M. Meyers, MD Department of Orthopaedic: Surgery
Reconstructive Hand Surgeons of Indiana College of Medicine
John D. Lubahn, MD Carmd, Indiana State University of New York
Hand Microsurgery and Syracuse, New York
Reconstructive Orthopaedics Alexander D. Mih, MD
Erie, Pennsylvania Associate Professor of Orthopaedic Surgery Alexander H. Payatakes, MD
Indiana University School of Medicine Assistant Professor of Orthopaedics
ShaiLuria,MD Indianapolis, Indiana Penn State College of Medicine
Assistant Professor Penn State Milton S. Hershey Medical
Department of Orthopaedic: Surgery Bruce A. Monaghan, MD
Advanced Orthopedic Centers Center
Hadassah-Hebrew University Medical Hershey, Pennsylvania
Center Woodbury, New Jersey
Hand and Microvascular Surgeon Chaitanya S. Mudgal, MD, MS(Orth.), Craig S. Phillips, MD
Department of Orthopaedic Surgery MCh(Orth.) Illinois Bone & Joint Institute
Hadassah Medical Organization Instructor, Orthopaedic Surgery Glenview, lllinois
Jerusalem, Israd Department of Orthopaedics Vimala Ramachandran, MD
David H. MacDonald, DO Harvard Medical School Northern Arizona Orthopaedics
Hand and Upper Extremity Specialist Massachusetts General Hospital Flagstaff, Arizona
Department of Orthopaedic: Surgery Boston, Massachusetts
Naval Hospital Jacksonville Ghazi Rayan, MD
Peter M. Murray, MD Clinical Professor of Orthopedic: Surgery
Jacksonville, Florida Professor of Orthopaedic: Surgery Adjunct Professor
Anna-Lena Makowski, Mayo Clinic Department of Anatomy/Cell Biology
Histotechnologist, HTL Jacksonville, Florida Oklahoma University
Miami International Hand Surgical Daniel}. Nagle, MD Director, Oklahoma Hand Fellowship
Services Professor of Clinical Orthopedics Program
North Miami Beach, Florida Northwestern University Feinberg School Chair, Division of Hand Surgery
of Medicine INTEGRIS Baptist Medical Center
Kevin J. Malone, MD Oklahoma City, Oklahoma
Assistant Professor Northwestern Memorial Hospital
Department of Orthopaedic Surgery Chicago, lllinois Marc Richard, MD
MetroHealth Medical Center Mitchell E. Nahra, MD Assistant Professor
CWRU School of Medicine Lake Orthopaedic: Associates, Inc:. Department of Orthopaedic: Surgery
Cleveland, Ohio Mentor, Ohio Duke University Medical Center
Durham, North Carolina
Alexander M. Marcus, MD Sanjiv Naidu, MD, PhD
Orthopedic: Associates of Central Jersey, PA Pinnacle Hand Center RossJ. Richer, MD
Edison, New Jersey Mechanicsburg, Pennsylvania Orthopaedic: Specialty Group, PC
Fairfield, Connecticut
Andrew D. Markiewitz, MD, MBA Brian Najarian, MD
Assistant Professor Associate Clinical Professor David Ring, MD, PhD
Department of Surgery Department of Orthopaedic Surgery Associate Professor of Orthopaedic: Surgery
Uniformed Services University of the St. John Providence Hospital & Medical Harvard Medical School
Health Sciences Center Orthopaedic Hand and Upper Extremity
Clinical Assistant Professor Southfidd, Michigan Unit
University of Cincinnati Massachusetts General Hospital
Cincinnati, Ohio Boston, Massachusetts

Kyle P. Ritter, MD David J. Slutsky, MD, FRCS(C) Joseph J. Thoder, MD

Hendricl<s Orthopaedics and Sports Assistant Clinical Professor Professor
Medicine David Geffen UCLA School of Medicine Department of Orthopaedic: Surgery
Danville, Indiana Chief of Reconstructive Hand Surgery Temple University Hospital
Department of Orthopaedics Philadelphia, Pennsylvania
Joseph E. Robison, MD
Harbor-UCLA Medical Center
Fayetteville Orthopaedics and Sports Christopher J. Thomson, MD
The Hand and Wrist Institute
Medicine Fellow, UAB Hand and Upper Extremity
Torrance, California
Fayetteville, North Carolina Fellowship
Matthew J. Robon, MD Hugh M. Smith, MD Department of Orthopaedic: Surgery
Proliance Orthopaedics & Sports Medicine Assistant Professor of Anesthesiology University of Alabama at Birmingham
Bellevue, Washington Mayo Clinic: Birmingham, Alabama
Rochester, Minnesota
Melvin P. Rosenwasser, MD E. Bruce Toby, MD
Robert E. Carroll Professor of Orthopedic Dean G. Sotereanos, MD Department of Orthopaedic: Surgery
Surgery Professor of Orthopaedic: Surgery The University of Kansas Hospital
Chief Drexel University College of Medicine Kansas City, Kansas
Orthopedic Hand and Trauma Surgery Allegheny General Hospital
Pittsburgh, Pennsylvania Matthew M. Tomaino, MD
Department of Orthopedic: Surgery
Tomaino Orthopaedic Care for Shoulder,
Columbia University College of Physicians Edwin E. Spencer, Jr., MD Hand, & Elbow
and Surgeons Attending Surgeon Rochester General Health System
New York, New York Shoulder and Elbow Center Rochester, New York
Justin M. Sacks, MD Knoxville Orthopaedic: Clinic:
Assistant Professor Knoxville, Tennessee Thomas Trumble, BA, MD
Department of Plastic Surgery Professor and Chief, Hand and Upper
Rena L. Stewart, MD
The University of Texas/MD Anderson Extremity Surgery
Associate Professor of Surgery Department of Orthopaedics/Sports
Cancer Center Department of Orthopaedic: Surgery
Houston, Texas Medicine
University of Alabama at Birmingham
University of Washington School of
Rodrigo Santamarina, MD Birmingham, Alabama Medicine
Plastic Surgeon Robert J. Strauch, MD Seattle, Washington
Fellowship-trained Hand Surgeon Professor of Clinical Orthopaedic Surgery
Assistant Professor of Surgery Richard L. Uhl, MD
Columbia University Medical Center
University of Massachusetts Professor of Surgery
New York, New York Division of Orthopaedic Surgery
Berkshire Medical Center
Pittsfield, Massachusetts James W. Strickland, MD Albany Medical College
Clinical Professor of Orthopaedic Surgery Albany, New York
Keith A. Segalman, MD
Assistant Professor of Orthopaedic Surgery Indiana University School of Medicine Ann E. Van Heest, MD
Johns Hopkins School of Medicine Reconstructive Hand Surgeons of Indiana Professor of Orthopaedic Surgery
Baltimore, Maryland Carmel, Indiana University of Minnesota
Greater Chesapeake Hand Specialists Eric Stuffmann, MD Minneapolis, Minnesota
Lutherville, Maryland Chief Resident of Orthopaedic Surgery Thomas F. Varecka, MD
David B. Shapiro, MD Stanford University Medical Center Assistant Professor of Orthopaedic Surgery
Section of Hand and Upper Extremity Redwood City, California University of Minnesota
Surgery Robert M. Szabo, MD, MPH Director, Hand and Microsurgery
Department of Orthopaedic: Surgery Professor of Orthopaedic: Surgery and Hennepin County Medical Center
The Cleveland Clinic Plastic Surgery Minneapolis, Minnesota
Cleveland, Ohio Chief, Hand, Upper Extremity, & Luis 0. Vasconez, MD
Joseph M. Sherrill, MD Microvascular Surgery Professor of Surgery
Clinical Assistant Professor of Surgery Department of Orthopaedic: Surgery Division of Plastic Surgery
Department of Orthopaedic: Surgery University of California, Davis School of University of Alabama at Birmingham
University of Alabama at Birmingham Medicine Birmingham, Alabama
Orthopaedic Sports Medicine Clinic Sacramento, California
of Alabama Thanapong Waitayawinyu, MD
Birmingham, Alabama JaneS. Tan, MD Assistant Professor
Department of Orthopaedic: Surgery Department of Orthopaedics
Alexander Y. Shin, MD Kaiser Permanente Thammasat University
Professor of Orthopedic: Surgery Denver, Colorado Klongluang, Pathumthani, Thailand
Mayo Clinic:
Rochester, Minnesota JohnS. Taras, MD John J. Walsh IV, MD
Associate Professor Associate Professor
Joseph F. Slade m, MDt Department of Orthopaedic: Surgery Department of Orthopaedics
Professor of Orthopaedics and Plastic Thomas Jefferson University University of South Carolina School of
Surgery Chief, Division of Hand and Surgery Medicine
Department of Orthopaedics and Associate Professor Columbia, South Carolina
Rehabilitation Department of Orthopaedic: Surgery
Yale University School of Medicine Drexel University Christina M. Ward, MD
Guilford, Connecticut Philadelphia, Pennsylvania Department of Orthopaedic: Surgery
University of Minnesota
Robert R. Slater, Jr., MD Andrew L. Terrono, MD Minneapolis, Minnesota
Associate Clinical Professor Clinical Professor of Orthopaedics
Department of Orthopaedic: Surgery Tufts University School of Medicine
University of California, Davis New England Baptist Hospital
Folsom, California Boston, Massachusetts
t deceased

Lance G. Warhold, MD D. Patrick Williams, 00 Jeffrey Yao, MD

Division Director, Upper Extremity Hand Microsurgery & Reconstructive Assistant Professor
Department of Orthopaedic Surgery Orthopaedics Department of Orthopaedic Surgery
Dartmouth-Hitchcock Medical Center Erie, Pennsylvania Stanford University Medical Center
Lebanon, New Hampshire Redwood City, California
Rafael M. M. Williams, MD
Arnold-Peter Weiss, MD Wilson, Wyoming Elvin G. Zook, MD
R. Soot Sellers Scholar of Hand Surgery Professor Emeritus
Professor of Orthopaedics Andrew Wong, MD Division of Plastic Surgery
Assoc:iate Dean of Medicine Private Practice Department of Surgery
Brown University Medical School Arrowhead Orthopaedics Southern lliinois University School of
Providence, Rhode Island Redlands, California Medicine
Assistant Professor-Clinical Springfield, Illinois
Mark Wdczynski, MD Department of Orthopaedic Surgery
Department of Orthopaedic Surgery Lorna Linda University
Washington University School of Medicine Lorna Linda, California
St. Louis, Missouri


I ------------------------------------------------------------~

On the pages that follow you will find a relatively comprehensive listing of effective surgical
procedures for the treatment of most distal upper extremity disorders written by a large cadre
of experts in the field. This volume's 120 chapters are grouped into twelve sections based pri-
marily on the type of pathology and, when appropriate, the anatomi(; lo(;Stion. Ea~ chapter
provides a brief description of the essential anatomy, pathogenesis, natural history, physi(;al
and radiographic examination, and non-operative management. However, the majority of the
content is dedicated to providing the reader a detailed step-by-step operative guide supple-
mented with carefully chosen (;lini~ pi(;tures and (;Oior drawings. The chapters conclude
with a concise listing of criti~ operative pearls and pitfalls as well as a discussion of the post-
operative rehabilitation and the expC(;ted patient outoomes. The references are limited to
those few articles and chapters that directly relate to the disorders and treatments discussed.
Though the practi~ advice and expert opinion provided in this volume should serve as
a valuable resource for a wide array of readers, it is specifically designed for orthopaedic,
plastic, and general surgeons in training as well as those in practice. The brevity and focus of
the chapters together with the precise procedural format makes Operative Tedmiqua in
Hand. Wrist and Forearm Surgery an excellent text to review when preparing for a spC(;ifi(;
(;SSC. The operative procedures described are not included for historical interest, rather they
are chosen by the experts based on their extensive experience and assessment of their patient's
The final product seen herein represents the end result of heroic effurts by numerous in-
dividuals. First and foremost, the authors generously donatW their time and expertise in the
production of these template-based chapters. The template frequently added difficulty and
frustration for the authors but was necessary in order to produce a consistent and effective
chaptu format. The talented editorial staff and artists worked tirelessly and patiently assist-
ing the many authors and somehow managed to keep aU documents, .figures and tables
related to the numerous chapters organized and moving toward completion. Finally, the
Editor-in-Chief, Dr. Sam W. Wiesel, and the Executive Editor, Mr. Robert A. Hurley,
provided the vision, direction and support necessary to make this book, and others in this
series, a reality.


"Next to the Brain, the Hand is the greatest asset to man and to it is due the development of man's
-sterling BJ~~~Mll

I am honored to write the foreword for Operative Tedmiqua in Hand. Wrist, ll1ld Forearm Surgery,
edited by Thomas R. Hunt.
Firat, I am proud as a father acknowledging his son's accomplishment. Tom was a hand fellow with
Bill Bora and me at The University of Pennsylvania. His enthusiasm in learning the .field of upper extrem-
ity surgery translated naturally to a dedication to teaching the discipline. His skiD at this is reflected by
his rise to become the Chair of Orthopaedic Surgery and the Director of the Hand Surgery Service at the
University of Alabama, Birmingham. His skill in editing this text required the coordination of over 175
authors from around the world. The orchestration of this many surgical egos is no easy task and corralling
from them a coherent and worthwhile text demanded attention to thousands of details by a dedicated
mentor. Congratulations, Tom, you have more than earned it.
Secondly, I am proud to be have been included among the talented CQUection of authors whose chap-
ters oover the gamut of operative techniques from the hand to the elbow. The book is a practical guide
and an invaluable reference to a hand surgeon, whether novice hand trainee or wizened practitioner. It
offers insights into old standards and solutions to new and evolving hand CQnditiona. In clear detail, each
chapter defines a strategy and technique to expand the reader's confidence.
I particularly like the fact that most chapters emphasize anatomy because the highly technical proce-
dures described here require an intimate knowledge of upper extremity anatomy. In the 14th century, Guy
de Chauliac complained, "A surgeon ignorant of anatomy carves the body as a blind man carves wood."
Seven centuries later, this work puts that complaint to .rest. Each procedure in the book is presented with
a detailed description of the !11ll'gical anatomy and a clear delineation of the indications and aitical steps
to ensure succesafu.lsurgery. This book aUows the hand surgeon who uses it to provide knowledgeable
care to their patient. One can demand no more of a book than that.

A. Lee Ostennan, MD


The editors and the publisher would like to thank the resident reviewers who participated in the reviews of the manuscript and
page proofs. Their detailed review and analysis was invaluable in helping to make certain this text meets the needs of residents
today and in the future.

Danid Galat, MD Gautam.Yapik, MD Catherine M. Robertson, MD

Dr. Galat is a graduate of Ohio Sute Attending Physician Assistant Clinical Professor
UDi.ven.ity College of Medicine and the Mayo Orthopaedic Sutgery UCSD Orthopaedic Sutgery-Sports Medicine
Clinic Department of Orthopedic Sutgery DRMC Sports Medicine San Diego, California
re&dency program. Dubois, Pennsylvania
He is c:utrently serving at Tenwek HospitJll in Jonathan Schocueckcr, MD
Kenya as an orthopedic sutgeon. Greg T. Niamdri, M.D. Assistant Ptofe{;SOr
Amstam Professor Departments of Orthopaedics, Pharmacology
l..awre:llu V. Gulotta, MD Department of Orthopaedics (SMD) and Pe<liatrics
Fellow in Sports Medicine/Should« Surgery University of Rochatec Vanderbilt University
Hospital foe Special Surgery School of Medicine and Dentistry Nashville, Tennessee
New York, New York Rochester, New York

Dara Chafik, MD, JlbD

Southwm Shoulder, Elbow and Hand Center
Tuscon, Arizona

- Anatomy and Surgical
Chapter 1 Approaches of the Forearm,
Wrist, and Hand
f Asif M. 1/yas, Neal C. Chen, and Chaitanya S. Mudgal

DEFINITION • Unique to the hand. wrist, and forearm is the complex rela-
tionship of not only the muscles overlying bone but also the
• Safe surgical dissection and exposure require an in-depth close proximity and delicate balance of accessory anatomic
knowledge of anatomy. In no place is this more relevant than structures, including tendons, vessels, and nerves.
in the surgical approaches to the hand, wrist, and forearm.
• The critical aspect of successful surgical approaches is the ANATOMY
use of intemervoua planes. • The anatomy of the hand, wrist, and forearm is intricate and
These planes lie between muscles that are innervated by can be diacuased in many ways and in extensive detail. For the
different nerves. discussion in this chapter, anatomy wiU focus on the compart·
This allows extensive mobilization and exposure without ments of the hand and forearm, and their relevance to surgical
risk of muscle denervation. approaches (Table 1).

Table 1 Corn~ents of the Hand and For•rm

Compartments Origin Insertion Innervation
Abductor pollicis brevis Trapezium/scaphoid Radial base of thumb P1 Median (recurrent motor brand!)
Flexor pollicis brevis Trapezium Base of thumb P1 Median (recurrent motor brand!)
Opponens pollicis Trapezium Radial base of thumb P1 Median (recurrent motor brand!)
Adductor pollicis Capitate/third metacarpal Ulnar base of thumb P1 Ulnar
Abductor digiti minimi Pisifonn Ulnar base of small P1 Ulnar
Flexor digiti minimi brevis Hook of hamate Base of small P1 Ulnar
Opponens digiti minimi Hook of hamate Ulnar base of small P1 Ulnar
Dorsal intl!ros.sei (4) #2, 3, 4, 5 metacarpals Radial or ulnar base of P1 Ulnar
Volar intl!ros.sei (3) #2, 4, 5 metacarpals Radial or ulnar base of P1 Ulnar
Carpal Tunnel
Lumbricals/Fiexor tl!ndansl Flexor digitDrum l.atl!ralbands Median and ulnar
median nerve profundus tendons
Superficial Volar Forearm
Pronator teres Medial epicand)te Mid third of radius Median
Flexor carpi radialis Medial epicand)te Base of #2 metacarpal Median
Palmaris longus Medial epicandyle Palmar fascia of hand Median
Flexor carpi ulnaris Medial epicandyle Pisiform/base of #5 Median
Flexor digitDrum superficialis Medial epicandyle Base of #2, 3, 4, 5 P2 Median
Deep Volar Forearm
Flexor digitDrum profundus Ulna/Interosseus membrane Base of #2, 3, 4, 5 P3 Median (ant intl!rosseous branch)
Flexor pallicis !angus Distal third of radius Base of thumb P2 Median (ant intl!rosseous branch)
Pronator quadratus Distal third of ulna Distal third of radius Median (ant intl!rosseous branch)
Dorsal Forearm
Abductor pollicis !angus Mid-third dorsal radius Radial base of thumb MC Radial (post intl!rosseous branch)
Extensor pol lids brellis Mid-third dorsal radius Dorsal base of thumb P1 Radial (post intl!rosseous branch)
Extensor pol lids !angus Dorsal ulna Dorsal base of thumb Pl Radial (post intl!rosseous branch)
Extensor digitorum communis Lateral epicondyle Dorsal base of 12. 3, 4, 5 P3 Radial (post intl!rosseous branch)
Extensor indids proprius Dorsal ulna Dorsal base of #2 P3 Radial (post intl!rosseous branch)
Extensor digiti quinti Lateral epicondyle Dorsal base of 15 P3 Radial (post intl!rosseous branch)
Extensor carpi ulnaris Lateral epicondyle Dorsal base of 15 MC Radial (post intl!rosseous branch)
Supinator Lateral epicondyle PrGKimal third of radius Radial (post interosseous branch)
Mobile Wad
Brachioradialis Lat condyle humerus Distal radius styloid Radial
Extensor carpi radialis !angus Lat condyle humerus Dorsal base of #2 MC Radial
Extensor carpi radialis brevis Lat condyle humerus Dorsal base of 13 MC Radial (post intl!rosseous branch


SURGICAL MANAGEMENT • The hand table should be stable and weU secured and should
• All surgical approaches to the hand, wrist, and forearm war- allow adequate space for both the operative limb and the sur-
rant sound understanding of surface and dei::p anatomy, in- geon's elbow and forearm to minimize fatigue and enhance
temervous planes, and surgical technique. stability.
• Planning the surgical approach begins by identifying reliable • The stool should be stable and comfortable, with the height
surface anatomy. set such that the knees are level with the hips and the feet are
resting flat on the ground.
Preoperative Planning • The lights should be angled directly over the hand table, and
• Arrangements for instruments, sutures, microscope, imaging not from behind the surgeon or assistant's shoulder, to prevent
support, implants, and assistants should be made before the shadows on the operative field.
day of surgery. • The use of a pneumatic tourniquet is advised to maintain a
• Anatomy, radiographic templating, surgical approach, pro- bloodless .field and clear visualization of all anatomic stru.ct:ure8.
cedure, and alternatives should be reviewed.
Positioning • Multiple approaches to the hand, wrist, and forearm exist
• Most approaches to the hand, wrist, and forearm can be and are beat divided into the anatomic site and ~tion of
performed with the patient supine and the operative extremity exposure.
extended on a hand table and the surgeon and assistants • The approach should be chosen based on the indication for
seated. surgery.


• Incisions in the hand can be placed almost anywhere as for maceration due to moisture, and tendency toward
long as certain principles are respected. poor apposition of skin edges on closure.
• Incisions should be outlined by sterile surgical markers
before making the actual incision to confirm appropriate
• Incisions perpendicular to a volar flexion crease should
be avoided to prevent scar formation and secondary skin
position, to confirm the adequacy of skin bridges should contractures that can lead to loss of motion and func-
multiple incisions be used, and to help guide closure. tional impairment (IEat RG 1A,B}.
• Incisions can be made in skin creases on the volar aspect • Incisions on the dorsal surface of the hand can be smaller
of the hand but incisions in deep creases should be due to the more mobile and loose nature of the dorsal
avoided due to the thin subcutaneous tissue, tendency skin (IECH FIG 1C).

TECH FIG 1 • Examples of volar (A.B) and dorsal

(C} incisions for the hand and digits.
• Vertical, horizontal, and curved incisions can all be • Midaxial incisions are best placed at the junction of
used with good facility as long as adequate skin glabrous and nonglabrous skin, with attention
bridges are maintained. being paid to the neurovascular bundle that sits in
• Fingers can be exposed dorsally, volarly, or midaxially. the plane of the flexor sheath. The neurovascular
• Dorsal incisions can be longitudinal or curvilinear. bundle can be taken volarly with the volar flap or
• Volar incisions are bert facilitated by a zigzag pattern can be left in place by carrying the dissection super-
that crosses creases laterally and at angles. ficial to it.


• Straight dorsal longitudinal incisions can be made or a • Three techniques can be employed to approach the joint:
variety of curved incisions can be used, including an S- • The lateral bands can be freed and gently retracted
type and a chevron style (IECH FIG 2A). dorsally, allowing a lateral approach into the joint.
• In the distal interphalangeal joint. caution must be paid • When more exposure is required, the lateral bands
to the germinal matrix, which is about 1 mm distal to the can be incised in line with the extensor mechanism
attachment of the extensor tendon. and repaired later.
• At the proximal interphalangeal joint, there is no inter- • Lastly, to maximize exposure of the joint,. the exten-
nervous plane and the extensor mechanism should be sor mechanism is cut dorsally in a long distally based
immediately evident (IECH FIG 21). V-shaped flap, raised, and later repaired.
• The integrity of the central slip inserting in the middle • It is critical not to detach the central slip distally and to
phalanx guides exposure of the proximal interpha- maintain continuity of the extensor mechanism through
langeal joint. the lateral bands on each side (IECH FIG 2C).

TECH FIG 2 • A. Examples of dorsal proximal and

distal interphalangeal joint skin mc1S10ns.
B. Extensor mechanism at the proximal interpha-
langeal joint. A. lateral band; B, extensor mecha-
nism;<:. proximal interphalangeal joint. c. Exposure
of the proximal interphalangeal joint by a distally
based V-flap elevation of the extensor mechanism.
A, proximal phalanx; B, proximal interphalangeal
c joint; C, reflected extensor tendon.


• Wrth the metacarpophalangeal joint flexed, identify the • If multiple joints are being approached, a transverse
apex of the joint,. which is the metacarpal head, and the incision centered dorsally connecting each of the
extensor tendon. joints may be used (IECH FIG 3A).
• Make a straight dorsal longitudinal incision centered • There is no internervous plane. The extensor mechanism
over the metacarpophalangeal joint. should be immediately evident. sensory branches of

either the radial or ulnar nerve, depending on which

joint is being approached, should be identified and pro-
tected (IECH RG 38).
• Three techniques can be employed to approach the
metacarpophalangeal joint:
• The sagittal band that runs like a sling around the
joint can be freed and retracted distally, exposing the
dorsal capsule of the metacarpophalangeal joint.
This technique is best used for a dorsal capsulo-
tomy or capsulectomy.
• When further e:xposure is required, the extensor mech-
anism is incised centrally and longitudinally through
the substance of the tendon. Extensile exposure of the
joint will be obtained immediately deep to the tendon.
This technique maintains balance of the extensor
I mechanism and avoids postoperative subluxation
and deviation.
The tendon split should stop before the level of
the proximal interphalangeal joint to avoid com-
promise of the central slip.
• The extensor mechanism can be incised along the
ulnar sagittal band in line with the tendon.
Release of the radial sagittal band should be
avoided to prevent postoperative ulnar subluxa-
tion of the tendon.
This technique also provides extensile exposure of
the metacarpophalangeal joint as well as the col-
c lateral ligaments but risks postoperative tendon
subluxation or finger deviation (IEat FIG 3C:,D).

1ECH FIG 3 • A. Examples of metacarpophalangeal skin incisions. A

straight longitudinal incision can be placed over each joint. If multiple
joints are being approached, a single straighttransverse incision can be
used. B. Extensor mechanism overlying the metacarpophalangeal joint.
A. extensor tendon; B, ulnar sagittal band. C. The ulnar sagittal band is
incised in line with the extensor mechanism revealing the metacar-
pophalangeal joint. A, extensor tendon; B, reflected ulnar sagittal
band; C, metacarpophalangeal joint. D. The metacarpophalangeal joint
D is arthrotomized dorsal to the collaterals.


• Palpate the metacarpal subcutaneously. Identify overly-
ing extensor tendons.
• Make a straight dorsal longitudinal incision over the
metacarpal. If more than one metacarpal is being ap-
proached, then place the incision between adjacent
metacarpals (IEat RG 4).
• There is no true internervous plane. Overlying extensor
tendons must be identified and protected.
• Juncturae tendinae may CI'OSIS over the field while con-
necting two tendons. They should be maintained if possi-
ble; if not, they should be released and tagged for repair
before closure.
• Dorsal interossei are attached to either side of the
• Incise the periosteum of the metacarpal longitudinally
along its exposed dorsal ridge and raise the interossei
medially and laterally in a subperiosteal fashion. 1Eat AG 4 • Incision for approaching multiple metacarpals.
• The carpal tunnel is an enclosed fibro-osseous tunnel • Incise the subcutaneous fat in line with the skin incision.
that contains nine flexor tendons and the median nerve. Deep to the fat lies the longitudinally oriented superfi-
Its borders include the transverse carpal ligament (the cial palmar fascia (IECH FIG SC).
root), the carpal bones (the floor), the hook of hamate • Incise this fascia in line with the incision.
(ulnar waiO, and the scaphoid (radial waiO. • Avoid raising flaps radially or ulnarly to prevent
• The proximal extent of the tunnel lies at the level of skin devitalization and injury to branches of the
the distal wrist crease. palmar cutaneous branch of the median and ulnar
• Identify the interthenar depression, which lies between nerves.
the thenar eminence radially and the hypothenar emi- • Deep to the superficial palmar fascia lies the thick trans-
nence ulnarly (IECH FIG SA). verse carpal ligament.
• Palpate the hook of hamate and pisiform bone along the • Release this ligament in line with the skin incision,
ulnar base of the hand. paying attention to the median nerve lying deep to it
• Determine the cardinal line of Kaplan, the estimated dis- as well as being cautious of the recurrent motor
tal extent of the transverse carpal ligament.4 The cardi- branch of the median nerve, which could cross
nal line of Kaplan runs from the base of the first web through or across the transverse carpal ligament
space (with the thumb abducted in the plane of the (IECH RG SD).
palm) parallel to the proximal palmar crease toward the • Distal to the transverse carpal ligament, confirm
hook of hamate. release of the ligament both proximally and distally.
• Multiple incisions can be used depending on the sur- Distal release is confirmed on visualization of
geon's preference, ranging from a limited approach the •sentinel" pad of fat, which has a distinct yel-
(IECH RG SB) to an extensile one. low color different from that of the subcuta-
• The incision should be centered within the interthenar neous fat.
depression and in line with the third web space to avoid Proximal release is confirmed both visually and by
injury to the palmar cutaneous branches of the median feel and usually corresponds to the confluence of
and ulnar nerves.8 the transverse carpal ligament with the deep
• The internervous plane occurs between the palmar cuta- forearm fascia, generally located at the level of
neous branches of the ulnar and median nerves. the distal wrist crease.

TECH FIG 5 • A. Surface anatomy

ofthevolar hand. A, radial artery;
B, flexor carpi radialis tendon; C,
flexor carpi ulnaris tendon; D,
pisiform; E, hook of hamate; F,
distal pole of scaphoid; G, cardi-
nal line of Kaplan. B. Incision for
the limited incision carpal tunnel
approach. C. Superficial palmar
fascia of the hand. D. Partial re-
lease of the transverse carpal liga-
ment with the median nerve lying
deep to it. A, retracted superficial
palmar fascia; B, partially released
transverse carpal ligament; C, me-
dian nerve.

c D


• The canal of Guyon is an enclosed fibro-osseous
space at the ulnar base of the hand through which
• Avoid crossing the wrist flexion crease perpendicu-
larly. Extend it proximally along the radial border of
the ulnar neurovascular structures travel before inner- the flexor carpi ulnaris tendon (IECH RG 61).
vating and perfusing the intrinsic structures of the • Identify the flexor carpi ulnaris proximal to the wrist flex-
hand. ion crease and mobilize it ulnarly by releasing the fascia
• Its borders include the volar carpal ligament (the along its radial border. The ulnar artery and nerve will lie
roof), the transverse carpal ligament (the floor), just deep and radial to the tendon, with the nerve more
the pisiform (ulnar wall}, and the hook of hamate superficial and ulnar to the artery.
(radial wall}. • Follow the ulnar artery and nerve distally into the hand.
• Palpate the pisiform bone, which lies subcutaneously at • In the hand, the flexor carpi ulnaris tendon will insert
the ulnar base of the hand immediately distal to the into the pisiform and the ulnar artery and nerve will
wrist flexion crease in line with the flexor carpi ulnaris dive deep to the volar carpal ligament.
(see TECH FIG SA). • Releasing the volar carpal ligament radial to the pisiform
• Pal pate the hook of hamate, which lies about 2 em distal
and 2 em radial to the pisiform bone.
opens the roof of the canal of Guyon and decompresses
the ulnar artery and nerve. In the canal of Guyon, the
• This may be difficult to palpate in patients with large nerve splits into its motor and sensory branches. The
hands or those with well-developed hypothenar motor branch of the ulnar nerve dives below a fibrous
musculature. arch formed by the hypothenar musculature originating
• Palpate the flexor carpi ulnaris tendon, which runs along from the hook of hamate (IECH FIG 6().
There is a high frequency of anatomic variations of the
the ulnar aspect of the forearm and inserts into the pisi- •
form upon crossing the wrist flexion crease. ulnar neurovascular structures within the canal of
• Make a zigzag or curved incision between the pisiform Guyon, and a release of the canal must include not only
and hook of hamate and extend it proximally the roof but also the distal extent of it as it enters below
(IECH FIG 6A}. the fibrous arch below the hypothenar muscles.5

A B c
TEat FIG 6 • A. Surface anatomy and incision for the approach to the canal of Guyon. A, pisiform; 8, hook of ha-
mate. B. The ulnar neurovascular structures in the base of the hand after release of the volar carpal ligament. A,
ulnar nerve; 8, ulnar artery and vein; C, pisiform with origin of the hypothenar muscles. C. Fibrous arch formed by
the hypothenar muscles over the motor branch of the ulnar nerve. A, ulnar nerve; 8, sensory branch of ulnar nerve;
C, motor branch of ulnar nerve.


• Identify the flexor carpi radialis at the wrist flexion most superficial muscle mass along the lateral forearm.
crease distally and follow it subcutaneously proximally Distally and laterally it has a broad insertion along the
(IEat RG 7A}. flare ofthe radial border ofthe radius.
• Its tendinous nature will give way to muscle at • Identify the biceps tendon, which is the broad and
roughly the middle of the forearm. taut extension of the biceps tendon that crosses ante-
• Identify the brachioradialis, which originates along the rior to the elbow joint and dives toward its insertion
lateral epicondytar ridge of the distal humerus and is the into the radius medial to the brachioradialis.
• Identify the radial artery at the wrist. It is found b~ nerve as it travels to the dorsal compartment of the
tween the flexor carpi radialis and brachioradialis forearm.
tendons. • To expose the radius proximally, the forearm must be
• Wrth the forearm supinated, begin the incision proximal fully supinated and the supinator is released along the
to the wrist flexion crease and immediately radial to the ulnar border of the radius and raised radially. The fore-
flexor carpi radialis tendon and extend the incision prox- arm must be kept fully supinated to protect the posterior
imally parallel to the tendon. interosseous nerve.
• The incision can end lateral to the biceps tendon and
distal to the elbow flexion crease.
• The incision can be extended as shown by the dotted
extensions in Techniques Figure 7A.
• The length of the incision depends on the extent of
bone that needs to be exposed.
• As described by Henry,3 the internervous plane distally
occurs between the flexor carpi radialis (median nerve)
and the brachioradialis (radial nerve). Proximally it occurs
between the pronator teres (median nerve) and the bra-
chioradialis (radial nerve).
• Distally the interval between the flexor carpi radialis
and the brachioradialis is developed (IEat FIG 71).
• The radial artery lies just ulnar to the brachioradialis
tendon and lies underneath the brachioradialis in the
middle of the forearm. Dissection should not drift
ulnar to the flexor carpi radialis, for the median nerve
lies just deep and ulnar to this tendon.
• The superficial radial sensory nerve exits from under
the brachioradialis at the middle of the forearm,
about 8 to 10 em proximal to the radial styloid, and
travels adjacent to the tendon distally.1 The nerve
arborizes proximal to the wrist joint.
• Proximally the interval between the pronator teres
and brachioradialis is developed.
• An alternative to the volar approach of Henry is the
trans-flexor carpi radialis approach.
• In this approach, the incision is placed directly over
the flexor carpi radialis tendon.
• The flexor carpi radialis sheath is opened sharply in
line with the tendon.
• The tendon is retracted ulnarly and the floor of the ten-
don sheath is opened sharply, leading directly into the
deep layer between the finger flexors and the pronator
quadratus, also known as the space of Parona.6
• several musdes lie over the radius in the deep layer• c
Distally, the pronator quadratus and flexor pollicis longus
cover the radius (~Eat AG 7C). On the middle third of the TEat FIG 7 • A. Surface anatomy and incision of the volar
forearm. A. flexor carpi radialis; B, radial artery; C, brachiora-
radius lie the flexor carpi radialis and pronator teres.
dialis; D, biceps tendon. B. Superficial exposure of the volar
• To expose the radius, these muscles are released along
radius showing the palmaris longus (;4) and the internervous
the volar radial aspect of the radius and are raised in a plane between the flexor carpi radialis (B) and the brachiora-
subperiosteal fashion ulnarly. dialis (D).c. radial artery. c. Deep exposure of the volar dis-
• Proximally, the supinator muscle covers the radius•
Through its substance travels the posterior interosseous
tal radius showing the pronator quadratus (B} covering the
distal radius. A, flexor carpi radialis; C, radial artery.


• Identify the tubercle of Lister at the distal and radial • Identify the lateral epicondyle of the distal humerus,
aspect of the radius. It is the most prominent bony which is the bony prominence most easily palpable prox-
protuberance on the dorsal distal radius, and the extensor imal to the radial head along the lateral aspect of the
pollicis longus tendon curves around it (TEat AG SA). elbow.
• Identify the "mobile wad of three," whidl is the common • With the foreann pronated, make the incision from the tu-
muscle mass composed of the brachioradialis and the ex- bercle of Lister and extend it proximally along the medial
tensor carpi radialis longus and brevis.3 border of the •mobile wad" toward the lateral epicondyle.

• The length of the incision depends on the extent of

bone that needs to be exposed (TEat FIG lA}.
• As described by Thompson, the internervous plane dis-
tally occurs between the extensor carpi radialis brevis (ra-
dial nerve, posterior interosseous nerve, or both) and the
extensor pollicis longus (posterior interosseous nerve).7
• Proximally it occurs between the extensor carpi radi-
alis brevis (radial nerve; inconsistent innervation) and
the extensor digitorum communis (posterior in-
terosseous nerve).
• Distally, develop the interval between the extensor carpi
radialis brevis and the extensor pollicis longus with the tu-
bercle of Lister positioned between them (IEat FIG 88). A
• Exposing proximally, the interval between the extensor
carpi radialis brevis and the extensor digitorum commu-
nis is identified by the emergence of the outcropping ab-
ductor pollicis longus and the extensor pollicis brevis
(IEat RG 8().
• Distally the radius sits immediately below the superficial
extensor tendons.
• To expose the distal radius, the extensor retinaculum
and the sheath of the extensor poll icis longus tendon
is opened and the tendon is retracted radially.
• The floor of the tendon sheath is incised longitudinally
and the extensor tendons are raised subperiosteally,
with the extensor carpi radialis longus and brevis taken
radially and the finger extensors taken ulnarly.
• Proximally, the abductor pollicis longus and extensor pol-
licis brevis cover the middle third of the radius.
• To expose the radius, these muscles are released
along their radial border, to avoid denervation, and
raised ulnarly.
• The proximal third of the radius is covered by the
supinator. Within its substance and between its two
heads runs the posterior interosseous nerve.
• Exposure of the dorsal radius proximally requires expo-
sure and protection of this nerve before elevating the
supinator off the radius.
c L-~. .~--------~~
• First, identify the nerve as it exits between the two
heads of the supinator. TEat FIG 8 • A. Surface anatomy and incision of the dorsal
forearm. A tubercle of Lister; B, ulnar border of the •mobile
• Follow the nerve proximally through the substance of
wad of threeH; C. lateral epicondyle. B. Superficial exposure of
the supinator's superficial head while taking care to
the dorsal distal radius. A tuberde of Lister; B, extensor carpi
preserve all its branches. radialis longus and brevis; C, extensor pollicis longus; D, re-
• Once the nerve is identified along its entire course, flected extensor retinaculum. C. Musculature of the dorsal fore-
the supinator can be released along its radial border arm. A. extensor digitorum communis; B, extensor carpi radialis
and raised ulnarly. brevis; C.. abductor pollicis longus and extensor pollicis brevis.


• Identify the ulnar head and styloid distally with the fore- • Distally, the internervous plane occurs between the
arm in neutral rotation (TEat FIG 9) . flexor carpi ulnaris (ulnar nerve) and the extensor carpi
• Identify the subcutaneous border of the ulna. ulnaris (posterior interosseous nerve).
• Identify the tip of the olecranon proximally. • Proximally, at the level of the olecranon, the inter-
• With the forearm in neutral rotation, begin the nervous plan occurs for a short length between the
incision at the level of the head of the ulna but proximal flexor carpi ulnaris (ulnar nerve) and the anconeus
to the styloid. Extend the incision across the subcuta- (radial nerve).
neous border of the ulna proximally toward the • Distally, the interval between the flexor carpi ulnaris and
olecranon. The length of incision depends on the extent the extensor carpi ulnaris occurs along the subcutaneous
of the bone that needs to be exposed. border of the ulna.

• The dorsal branch of the ulnar nerve branches about 8

em proximal to the pisiform and crosses the subcuta-
neous border of the ulna as it travels dorsally about 5 em
proximal to the pisiform.2
• Proximally the interval remains along the subcutaneous
border of the ulna.
• The proximal aspect of the ulna receives the insertion of
the triceps tendon.
• When exposing the ulna proximally during deep dissec-
tion, the integrity of the triceps tendon is maintained by
incising the tendon in line with its fibers across the bor-
der of the ulna and raising it medially and laterally in a
TECH AG 9 • Surface anatomy and incision for the ulnar shaft. subperiosteal fashion.
A. ulnar head and styloid; 8, subcutaneous border of ulna. • The ulnar nerve travels around the medial epicondyle
and dives between the two heads of the flexor carpi
• Both muscles can be raised volarly and dorsally off the ulnaris.
ulna, respectively, in a subperiosteal fashion. • Before exposing the ulna's most proximal and medial
portion, the ulnar nerve should be identified and pro-
• The ulnar artery and nerve travel deep and radial to the
flexor carpi ulnaris. The nerve is protected by careful sub- tected, followed by subperiosteal elevation of the flexor
periosteal elevation of the flexor carpi ulnaris. carpi ulnaris.


Approach to the interphalangeal joints (proximal and distal} • Protect the germinal matrix and terminal tendon at the base of
the distal phalanx.
• Protect the central slip at the base of the middle phalanx.
Approach to the metacarpophalangeal joints • If necessary, release the ulnar sagittal band at the joint. Avoid
releasing the radial sagittal band.
Approach to the carpal tunnel • Protect branches of the palmar cutaneous branch of the median
and ulnar nerves in the subcutaneous tissue by centering the
incision in the interthenar eminence.
• Remain vigilant for a transligamentous recurrent motor branch
of the median nerve.
Volar approach to the radius • Dissection should not drift ulnar to the flexor carpi radialis ten-
don to protect the median nerve and its cutaneous branches.
Dorsal approach to the radius • The posterior interosseous nerve ends at the level of the wrist
dorsally in line with the fourth metacarpal and is easily ap-
proached for denervation for postoperative pain relief.

REFERENCES 5. Konig PS, Hage JJ, Bloem JJ, et aL Variations of the ulnar nerve and
1. Abrams RA. Brown RA. Bot:!Z MJ. Tb.e superficial branch of the ra- ulnar artery in Guyon's amal: a cadaveric: study. J Hand Swg 1994;
dial nerve: an anatomic: study with sUigic:al implications. J Hand Swg 19:617-622.
1992;17:1037-1041. 6. Parona F. Dell'onc:otomia negli ac:c:essi profundi diffuse dell'avam-
2. Bette MJ, Cohen MS, Lavemia CJ, et aL The dorsal branch of !he bracbio. Amlali Uuiversali di Medicina e Chirurgia Milano, 1876.
ulnar nerve: an anatomic: study. J Hand Swg 1990;15:603-607. 7. Thompson JE.. Anatomical methods of approach in operations on the
3. Henry AK. Extemile exposure, 2nd ed. Edinburgh: E&S Livinptone, long bones of the extremities. Ann Surg 1918;68:309-32.9.
1966. 8. Watthmaka GP, Weber D, Mackinnon SE.. Avoidance of transection
4. Kaplan EB. Functional and sw:gic:al anatomy of the hand, 2nd ed. of the palmar cutaneous branch of !he median Dern'! in carpal tunDel
Philac:l.elphia: JB Lippincott, 1965. release. J Hand Surr; 1996;21:644-650.
- Anesthetic Considerations
Chapter 2 for Surgery of the Upper
t John A. Dilger and Hugh M. Smith


• Orthopaedic surgery makes up a considerable portion of the Rheumatoid Arthritis
70% of procedures done on an ambulatory basis in the United • In advanced rheumatoid arthritis, atlantoaxial subluxation
States.9 may develop from erosion of ligaments at the odontoid
• Several factors have fueled this growth in outpatient or· process of C2 as it is attached to Ct. This C1 and C2 instabil-
thopaedic surgery, including less invasive surgical approaches, ity may produce subluxation, resulting in cord compression
changes in practice patterns, and the introduction of anesthetic and paralysis.
agents associated with fewer postoperative side effects. Anatomic changes involving the cervical spine, temporo-
• Postoperative pain management represents a particular chal- mandibular joint, or arytenoids may necessitate awake air-
lenge with ambulatory surgery, as 40% of patients experience way management with a .fiberoptic bronchoscope (Table 1).
severe pain despite treatment.5 Preoperative .flexion and extension films are indicated
• Regional anesthesia techniques have been used to solve this with advanced rheumatoid arthritis, and cervical fusion of
problem. C1 to the occiput may be required before the procedure.
Anesthetic techniques incorporating peripheral nerve Regional anesthesia may avoid the airway challenges of
blocks are associated with superior analgesia and a lower in- general anesthesia, but it may be difficult in these patients if
cidence of postoperative nausea and vomiting.12•15 the loss of range of motion in the joints prevents proper nee·
Regional anesthetic techniques result in increased patient dle placement.
satisfaction and fewer unanticipated hospital admissions.23 • Rheumatoid arthritis is associated with cardiovascular dis-
• Peripheral nerve blocks administered with a single dose of ease, and atherosclerosis occurs at an accelerated rate in
long-acting local anesthetic (bupivacaine or ropivacaine) have rheumatoid arthritis, resulting in a greater risk of myocardial
frequently been used to provide postoperative pain control. infarction and cerebrovascular accident?
However, patients and surgeons alike become .frustrated when The rate of cardiovascular morbidity and mortality in
these blocks dissipate in the middle of the night, resulting in rheumatoid arthritis is higher than the general population.19
the return of severe pain. In these situations, the pain state is • Rheumatoid arthritis also causes deteriorations in respira-
longer than the duration of the block. tory performance as the lungs become affected, resulting in re-
• Despite the selection of long-acting local anesthetics (14 to strictive pulmonary disease.17
24 hours of analgesia), about 20% of patients after orthopae- • Preoperative evaluations including an echocardiogram and
dic surgery have significant pain requiring opioids after cardiac stress and pulmonary function testing should be con-
7 days.14 sidered in patients with severe rheumatoid arthritis.
Continuous regional analgesia, using an indwelling nerve
catheter and local anesthetic pump, can maintain analgesia Trauma
until the pain state dissipates. • Surgical emergencies may require general anesthesia before
• The frustration with the limited analgesia provided by a sin· completing radiologic evaluations.
gle dose of local anesthetic causes some physicians to avoid An uncleared cervical spine requires in-line manual stabi-
nerve blocks altogether. They choose instead to use an opioid lization during the endotracheal intubation, regardless of
strategy begun preoperatively with sustained-release analgesics
(oxycodone SR).
This approach is associated with increased side effects Facton Associated wi1h
such as urinary retention, pruritus, ileus, nausea, and Table 1 Difficult Endotracheal
vomiting. Intubation
• If continuous regional analgesia is selected, it may be used
for anesthesia and postoperative analgesia. Anatomic: abnonnalities: miaognathia, limited jaw or ned. mobility
• The continuous peripheral nerve catheter offers prolonged Cervical spine fusion
analgesia and minimal side effects and eliminates the problem Trauma
Ankylosing spondylitis
of block resolution and the return of severe pain. The nerve
Juvenile rflec.~matoid arthritis
block is maintained with a continuous infusion of local anes·
Adult rfla.unatoid arthritis
thetic agents. Achondroplasia
Pumps have been developed allowing outpatient infu- Acromegaly
sions, and these elastomctric pumps are ideal because they Piene Robin syndrome
are compact, simple to operate, and designed to provide safe Tread!er Collins syndrome
infusion rates of local anesthetic in the uncontrolled home Goldenhar syndrome

11 -

Fasting Guidelines for

Table 2 Pediatric Patients

F-.ting lime (hr)

Age Milk and Solids Clear Liquids
<6mo 4 2
6-36mo 6 3
>36mo 8 3

• Regional anesthesia decreases anesthetic and opioid re-

quirements, resulting in shorter wakeup times with general
• Caudal and spinal blocks have been the most commonly
used regional techniques due to the anesthesiologist familiarity
and their relative safety when perfo.rmed in the anesthetized
FIG 1 • Pediatric axillary brachial plexus block. • Nerve blocks may provide preemptive analgesia by blocking
painful stimuli and lead to lower stress hormone levels and less
whether the intubation is performed with the patient awake overall pain.18
or asleep. Nerve blocks done while the patient is under anesthesia
• General anesthesia is .frequendy used for orthopaedic ttawna. have caused severe injury in adults, but these injuries are
Factors that .influence this decision include sw:gery on more much less common in children.16
than one extremity, unknown duration of procedure, the need Ultrasound-guided nerve blocks during general anesthesia
to :wess postoperative neurologic function, and surgeon or pa- may reduce the risk of nerve injury, allowing dir&:t visual-
tient preference. ization of neural targets.
• Nerve blocks with concentrated local anesthesia (bupivacaine • Pediatric regional techniques require smaller needles, which
or ropivacaine 0.5% or higher) can mask symptoms of com- have only recently become available, but continuous blocks
partment syndrome and should be avo.ided in patients at risk. are done with adult equipment. a less-than-optimal situation.
• Advantages of regional anesthesia for upper extremity • Pediatric patients require cautious local anesthetic selection
ttauma surgery include: and administration to toxicity.
Increased blood flow in anesthetized area Epinephrine is typically added to enable the diagnosis of
Lower incidence of deep venous thrombosis with neurax:ial an intravascular injection of local anesthetic and to decrease
blocks its systemic absorption.
D&:reased blood loss • Fasting guidelines for children up to 3 years old are given in
Decreased postoperative nausea and vomiting Table2.
Avoidance of difficult endotracheal intubation • Pediatric doses of local anesthetics are summarized in
Decreased phantom limb pain following amputation by Table 3.
preventing pain centralization • Continuous peripheral nerve catheters offer the same advan-
tages in pediatric patients as in adults.
Pediatrics Recommended infusion rates begin at 0.15 mUkg per
• General anesthesia is often used in pediatric surgery because hour of bupivacaine 0.25%.22
children lack the emotional and intellectual maturity to be Continuous peripheral nerve catheters may be dosed
conscious during the procedure (FIG 1 ). with dilute local anesthetics (bupivacaine or ropivacaine
• Regional anesthesia may be performed in a child during gen- 0.1 %) because of incomplete myelinization of neural
eral anesthesia, but the loss of patient f«dback regarding pain fibers, permitting greater local anesthetic penetration. This
and paresthesia increases the risk of neural injury. will decrease the risks of local anesthetic toxicity.

Table 3 Pediatric Doses of Clinical O.aracteristics of Commonly Used Local Anesthetics*

Usual Usual Maximum Maximum DoH

Local Concentration Doses Dolle, Plain• with Epinephrine• latency Duration of
Anesthetic (%) (mgJkg) (mglkg) (mglkg) (min) Effects (hr)
Lidocaine 0.5-2.0 5 7.5 10 5-15 0.75-2.0
Prilocaine 0.5-1.5 5 7.0 10 15-25 0.75-2.0
Mepivacaine 0.5-1.5 5-7 8.0 10 5-15 1-1.25
Bupivacaine o.25-o.5 2 2.5 3 15-30 2.§.-6.0
Ropivacaine 0.2-10.0 3 3.5 NA 7-20 2.5-5.0

•Data are not appllalble to Sflll\lllanesttteslll or lntr8'1otef!Oij5 regional anesthesia.

Maxfmwn closes \'ary, frEt and unbowulloall c:auses toxkity, not total close. Do not apply If pre'WIOIISiy tl)eaed or loallanesthetlc IITiiislon mBintlltlecl

ANESTHESIA SELECTION FOR UPPER Table 5 Nerve Blocks for Surgery

• Anesthesia for arm and hand surgery may be general, re- Procedure Block
gional, or a ~ombination of teclmiques. Shoulder surgery lnll!rscalene
• The potential benefits of an upper extremity nerve block are Elbow surgery lnll!rscalene, supraclaviwlar, or
less nausea, a shorter re~overy, and faster discharge from the infraclavicular
hospital, in part due to improved postoperative analgesia, re- Forearm and hand surgery lntraclavicular, axillary or IV regional
quiring fewer narroti~s for pain.8 (short procedures <1 hour)
• The anesthetic plan may also be based on factors unrelated
to evidence-based medicine, su~h as anxiety, extended case du-
ration, or the need for immediate neurologic examination after
surgery. • No ~ontraindication
Carpel tunnel syndrome
General Anesthesia Multiple sclerosis (spinal anesthesia contraindicated)
• Easier to apply and no anesthetic failures Stroke
• Provides unconsciousness for the long procedure or un~om­ Diabetes mellitus
fortable position
• Pediatric and mentally retarded patients are easier to manage. Contraindicalions
• Cadaveric ronditions when the surgery requires no movement • Absolute
• Procedure and graft harvest can be in different anatomic Acute or resolving nerve injury m the regional block
locations. distribution
• Nerve function ~an be immediately assessed. Progressive peripheral neuropathy
• Efficient anesthesia recovery with anesthetics such as propo- Infection at the puncture site for the block
fol, sevoflurane, or desflurane Patient refusal
Bleeding disorder: full anticoagulation, thrombolytic ther-
Regional Anesthesia apy, and hemophilia
• Increases operating room efficiency: nerve blocks are done • Relative
before entering the operating room, eliminating the time Stable nerve impairment
needed for induction and emergence from anesthesia lnterscalene blocks with severe ~hronic obstructive pul-
• Simplified perioperative management with conditions such monary disease
as malignant hyperthermia, cardiomyopathy, and obstru~tive Fever, bacteremia
or restrictive lung conditions
• Continuous nerve blocks may provide anesthesia and be REGIONAL ANESTHESIA FOR UPPER
used for postoperative pain ~ontrol. EXTREN.ITTY SURGERY
• Propofol may be administered with regional blocks for light • Nerve blocks for upper extremity surgery are summarized in
or heavy sedation. Table 5.
• Less postoperative nausea and vomiting
• Faster re~overy from anesthesia and earlier discharge Shoulder Surgery
• Less postoperative cognitive dysfunction than from general • Be~ause of the intense perioperative pain, particularly with
anesthesia due to superior pain rontrol, fewer sleep distur- arthroplasty or open rotator cuff operations, general anesthe-
bances, and fewer unplanned admissions to the hospital sia is rarely the sole teclmique for shoulder surgery.
By avoiding unplanned admissions to the hospital, the in- • Performing regional anesthesia for shoulder surgery requires
cidence of postoperative ~ognitive dysfunction is lowered knowledge of the anatomy and the surgical approach.
from 9.8% to 3.5%.3 The shoulder is innervated primarily by the brachial
• American Society of Regional Anesthesia and Pain Medicine plexus, with minor contributions of sensory innervation
guidelines on anti~oagulation are given in Table 4. from the superficial ~ervical plexus (FIG 2 ).

Table 4 American Society of Regional Anesthesia Guidelines for


Medication Discontinuation Recommendation

Herbal medications: ginkgo, ginseng, and garlic (greall!st effect) No discontinuation
Nonsll!roidal anti-inflammatories and acetaminophen No discontinuation
Ticlopidine and clopidogrel 14 days
SQ No discontinuation
IV Stop and 1 hour after block.
Low-molecular-weight heparin 12 hours after last dose
Coumadin Discontinue 4 days
Thrombolytics Avoid regional
13 -
Brachial Plexus Blocks
"' I I I I
Ia.._•..,..., , I
1nftK11¥1tolot I
I I ..,.1,.,.


FIG 2 • Brachial plexus blocks. (By permission of Mayo

Foundation for Medical Education and Research. All rights

• The interscalene block is done at the level of the trunks and

blocks the superior and middle trunks along with the superfi-
cial cervical plexus.
Identification of superficial landmarks and the needle
puncture site is done by palpating the space created by the
trunks between the anterior and middle scalene muscles at
the level of the cricoid cartilage (FIG 3A).
The nerves can be localized using paresthesia. nerve stim-
ulator, or ultrasound (FIG 38).
Once the needle is in approximation to the brachial FIG 3 • A. lnterscalene block superficial landmarks. B. Axillary
plexus trunks, local anesthetic is incrementally injected, re- artery and surrounding nerves of brachial plexus.
sulting in anesthesia of the shoulder and proximal arm.
Interscalene blocks with bupivacaine or ropivacaine pro- without putting the patient supine and taking down the
vide perioperative analgesia. drapes for endotracheal intubation.
Interscalene blocks cause a sympathectomy and resultant Because of this potential problem, many anesthesiolo-
redistribution of blood away from the surgical site, decreas- gists and surgeons alike prefer to use general anesthesia
ing intraoperative blood loss. with an endotracheal tube in combination with an inter-
• Incisions and port holes are occasionally outside the block's scalene block.
anesthetic distribution, requiring local anesthetic to be inj&:ted This combined anesthetic would also be chosen with
by the surgical team into the affected area. complicated reoperations or where induced hypotension
Intra-articular local anesthetic and narcotic infusions may is needed.
be helpful but must be combined with interscalene blocks • Continuous interscalene blocks may be done to provide
for maximum postoperative analgesia analgesia for a prolonged period.
• The semisitting position is often selected for the surgery, and Typically 48 hours of postoperative pain is adequate, and
the table must be equipped with a head pi&:e securing the pa- catheters are then removed.
tient's head with a padded strap at the forehead. Prolonged interscalene analgesia may be required in acute
The semisitting and lateral decubitus positions place the surgical shoulder pain in the chronic pain patient or in a pa-
operative site above the heart, rarely resulting in air tient with a frozen shoulder requiring mobilization therapy.
embolism. Continuous interscalene blocks have been associated with
• Head and neck positioning is crucial to avoid spinal cord enhanced physical rehabilitation after shoulder surgery due
compression and neurologic deficits. However, the anesthesi- to superior pain control.6
ologist may be hampered by this position h«:ause the proxim- • Interscalene block side effects include phrenic nerve, recur-
ity of the surgical incision allows little access to the head. rent laryngeal nerve, and stellate ganglion blockade.
It may be very difficult to convert to general anesthesia These may result in transient loss of ipsilateral diaphragm
without disrupting the sterile surgical field when a patient function, weak voice, miosis, ptosis, and anhydrosis
with a regional anesthetic must be put to sleep in the middle (Homer syndrome).
of the procedure. General anesthesia can be administered
without endotracheal intubation either by holding a mask Elbow Surgery
on the face or by inserting a laryngeal mask airway while the • Surgical procedures at the elbow, whether for arthroplasty
patient remains in the semisitting position. or the reattachment of a biceps brachii tendon, frequendy re-
Although this does not provide protection from stomach quire general anesthesia despite the advantages of regional
content aspiration, it offers some control of the airway anesthesia.

• The proximity of nerves to the surgical incision is concern-

ing to sw:geons who may wish to examine neurologic function
in the immediate postoperative period, which is not possible
with a nerve block.
Regional teclullques are often performed in the recovery
area after nerve function is assessed.
• Functional outcomes after elbow surgery often depend on
early rehabilitation using continuous passive motion devices.
This therapy can be facilitated with continuous brachial
plexus analgesia. The infraclavicular and the axillary ap-
proaches to the brachial plexus are options for catheter
• The iofradavicular block is perfonned by placing the needle
1 inch distal to the middavide, with the needle advanced to·
ward the axillary pulsation until twitch or paresthesia is ob-
tained (FIG 4 ).
Continuous infraclavicular blocks are ideal as they cover
the brachial plexus, including the musculocutaneous nerves,
providing anesthesia of the entire arm.
Continuous axillary nerve blocks cover the brachial
plexus, with the exception of the musculocutaneous nerve.
This may result in pain during continuous passive motion
and it may need to be separately blocked.
• Surgery with brachial plexus blocks may require supplemen·
tation at the musculocutaneous and intercostobrachial nerves.
Hand Surgery
• Hand procedures are .frequendy done with nerve blocks be-
cause of the ideal operating conditions and early discharge
times postoperatively.
General anesthesia is reserved for extremely long cases
and is combined with brachial plexus analgesia.
• Carpel tunnel release surgery is one of the most common
hand procedures and may be done with an intravenous re-
gional block (Bier block).
Bier blocks are impractical for the efficient outpatient
practice. Local.irWltration by the sw:geon combined with in-
travenous sedation is a more common and efficient anes-
thetic approach.
• The axillary approach to the brachial plexus is ideal £or
more extensive hand procedures (FIG SA).
The block may be placed easily, sets up quickly, covers all
of the nerves of the hand, and is associated with low com-
plication rates.
The nerves in the axilla have a predictable anatomic rela-
tionship to the axillary artery.
The block may be done with paresthesia, nerve stimula-
tion, or transarterial approaches.
• Ultrasound guidance more recendy has been used to provide
real-time visualization of both the needle and the neural tar-
gets (FIG SB,C).
The success of the block can be predicted by confirming
circumferential spread of local anesthetic around the FIG 4 • A. Infraclavicular block superficial landmarks.
B. Continuous infraclavicular block catheter needle insertion.
C. Infraclavicular continuous catheter secured and labeled.
• Continuous peripheral nerve catheters may be placed if the
procedure is prolonged, a sympathectomy is needed, or signif-
icant pain is expected.
• Brachial plexus anesthesia with an intercostobrachial nerve • Often a "failed" block is simply the result of inadequate
block will prevent tourniquet pain, unlike general anesthesia. time for local anesthetic distribution to nerve targets.
• Insufficient blocks can be supplemented, and again ultra-
Supplementing Nerve Blocks sound offers a safe option for this.
• It is preferable to place blocks outside the operating room so • Propofol infusions will allow control of anxiety and can
that block efficacy can be evaluated. turn an incomplete block into an intraoperative success.
15 -

Axllllll)' Arte~

~ ~ineertion

FIG 5 • A. Patient positioning and superficial landmarks for axil-

lary approach. B. Sterile ultrasound probe and needle insertion
for sonographically guided axillary block. c. Real-time ultra-
I sound-guided axillary blockade.

Continuous Nerve Blocks • The efficacy of continuous interscalene blocks was demon·
• Postoperative pain control after a single inj&:tion of local strated in patients treated with ropivacaine 0.2% after open
anesthesia is limited to 16 hours, and this limits ita usefulness rotator cuff surgery; they achieved pain scores averaging 1 out
for postoperative pain management. of 10 compared to placebo.13
In a procedure associated with moderate to severe postop- Similar results were achieved with outpatient shoulder pa-
erative pain, patients experience significant pain when the tients sent home with continuous interscalene blocks.11
block resolves. • The efficacy of continuous infraclavicular blocks was demon-
Undertreated pain may result in more refractory pain strated when ropivacaine 0.2% was administered to outpatients
states, such as chronic pain or complex regional pain with moderately painful orthopaedic procedures; they achieved
syndromes. pain scores of 2 versus 6 in the placebo control group. The
• Because of the anatomic relationships of the upper extrem- blocks were associated with less pain, resulting in fewer sleep
ity, a single catheter may provide continuous analgesia in the disturbances, less opioid consumption, and .fewer side e~ta. 10
distribution of surgical pain. • Infusion pumps maintain the block by infusing dilute local
The catheter is placed and local anesthetic administered anesthetic (bupivacaine 0.1% and ropivacaine 0.2%) at 10 cdhr.
preoperatively and combined with other analgesic inter- • Local anesthetic toxicity resulting from the continuous infu-
ventions. sion is very rare. Local anesthetic toxicity is most likely during
The surgical pain is not amplified at the tissue level or the initial injection (bolus with 30 to 40 cc of bupivacaine or
centrally in the spinal cord, so the pain is less intense and of ropivacaine 0.5% ).
shorter duration.2°
• Continuous blocks may be maintained in the hospital as Local Anesthetics and Additives
well as at home using disposable infusion pumps. To ensure • Local anesthetics produce anesthesia by inhibiting excita·
success with home-going regional anesthesia, instructions and tion of nerve endings and blocking conduction in peripheral
teaching must begin in the preoperative period. nerves due to the binding and inactivation of both sodium and
Patients must be coWl.Seled about the danger of injury in potassium channels. This prevents the sodium influx througlt
the absence of normal pain responses. They are instructed to these channels that is necessary for the depolarization of nerve
avoid working with extreme heat or cold and to avoid cell membranes and propagation of impulses along the course
driving. of the nerve.
Patients are educated about symptoms of local anesthetic • There are two classes of local anesthetics, named for their
toxicity, and phone numbers are provided with instructions linkage between the carbon chain and aromatic chain.
to call in the event of problems. The amino amides have an amide link between the chain
When continuous peripheral nerve catheters are part of a and the aromatic end, and amino esters have an ester link
multimodal pain therapy consisting of nonsteroidal anti- between the chain and the aromatic end.
inflammatory medications, acetaminophen, cryotherapy, The amino esters are metabolized in the plasma via
and weak opioids, greater analgesia and patient satisfaction pseudocholinesterases, and amino amides are metabolized
may be achieved. in the liver.

Table 6 Local Anesthetic Dosages

Usual Usual Maximum Maximum Dose

Local Concentration Doses Dose, Plain'~' with Epinephrine... Latency Duration of
Anesthetic (%) (mglkg) (mglkg) (mgJkg) (min) Effects (hr)
Lidocaine 0.5-2.0 5 7.5 10 5-15 0.75-2
Mepivacaine 0.5-1.5 5-7 7.5 10 5-15 1-1.25
Bupivacaine 0.25-0.5 2 2.5 3 15-30 2.5-6.0
nerve block 15)
Ropivacaine 0.2-10.0 3 3.5 NA 1Q-20 2.5-5.0
nerve block 14)

tEpinephrine is 1:200,000 concentration.

Amino esters are eliminated rapidly compared with EQUIPMENT

amides, deu-easing the possibility of toxicity. Airway Management
Amino esters are much more likely than amino amides
to cause true allergic reactions due to metabolites like • For 30 minutes after a nerve block, patients must be closdy
para-aminobenzoic acid. monitored for signs of systemic toxicity.
• Varying the concentration of local anesthetics will produce • Medications to treat seizures and to establish general anes-
a differential block. Higher concentrations produce an intense thesia must be immediatdy available.
motor and sensory block. More dilute locals result in a sensory • Induction drugs such as propofol and succinylcholine and
block with little motor blockade. airway equipment, including oxygen, an Ambu-bag with mask
• Toxicity from local anesthesia occurs when a peak plasma for positive-pressure ventilation, and a laryngoscope with as-
levd is reached, typically from inadvertent intravascular ad- sorted endotracheal tubes, should be nearby.
ministration of anesthetic. Monitoring
Toxicity from rapid absorption is also possible, especially • The rare occurrence of local anesthetic toxicity mandates
in vascular areas (intercostal, epidural, or interscalene), and full monitoring in the operating room and in areas where
epinephrine is added to the local anesthetic to signal in- blocks may be done before surgery.
travascular injection and decrease the vascular absorption of • Pulse oximetry measures blood oxygen saturation in re-
the local anesthetic. sponse to sedatives and analgesics, and the electrocardiogram
The inadvertent intravascular injection of bupivacaine or is required to diagnose rhythm changes in the unlikdy event of
ropivacaine may result in cardiovascular collapse (ventricu- cardiac toxicity.
lar tachycardia or fibrillation). • Observation of the patient for early signs of central nervous
Because of their potent binding to the heart, these ar- system excitation is perhaps the best monitoring practice.
rests can be difficult to treat.
Cardiotoxicity from bupivacaine has been successfully Regional Equipment
treated with 2 milkg of 20% lipid emulsion in a case re- • The practice of regional anesthesia requires special equip-
port.21 The mechanism of the lipid emulsion is the bind- ment designed for peripheral nerve blockade.
ing of bupivacaine in the plasma and tissues. In other • The nerve stimulator allows confirmation of the needle po-
cases patients have required cardiopulmonary bypass sition adjacent to the nerve when a motor response is seen with
until the conduction blockade resolved. low current output (0.5 rnA; FIG 6 ).
• Recommended doses of local anesthetics are given in Table 6. In today's clinical practice, continuous nerve blocks for
• The use of additives with local anesthetics has increased as pain control are commonly placed using nerve stimulation.
regional analgesia has become a standard method for manag- • A newer technique uses ultrasound to visualize the nerve to
ing postoperative pain. be blocked.
Some additives prolong the duration of the block and With ultrasound, it is possible to visualize, in real time,
therefore the postoperative pain control (Table 7). images of the nerve, the needle approaching the nerve, and

Table 7 Additives to Local Anesthetics

Additive Dosage Eflect on Intermediate Local Anesthetic

Epinephrine 2.5 ~~og/ml Prolonged
Clonidine 1.0 ~~oglkg Prolonged
Opioids (alfentanil, sufentanil, morphine) None
Buprenorphine 0.3mg None
Neostigmine None
Ketamine None
Sodium bicarbonall! 1.0 mEq/10.0 ml Faster onset
17 -

FIG 6 • A. Regional anesthesia sterile tray and stimulating needle. B. Regional anesthesia stimulating needle and catheter. C. Nerve
stimulator. D. Portable ultrasound machine and transducers.

the local anesthesia or catheter be.iug placed in the space • A dense. sustained nerve block inhibits the transmission of
around the nerve. noxious afferent stimuli from the operative site to the spinal
cord and brain.
PAIN MANAGEMENT • Muhimodal pain control uses multiple analgesics affecting
Preemptive Analgesia multiple pathways to maximize analgesia (Table 8).
• Preemptive analgesia is implemented before a painful stimu- These interventions complement each other and often
lus. which limits the sensitization of the nervous system to the allow smaller individual drug doses to be used, thereby min·
pain. This should result in less intense pain of shorter duration. imizing side effects.

Table 8 Nonopioid Analgesics

AnalgMic Dosage Interval Route Maximum Dose Comments
Aspirin 3()()-.f()() q~h PO 3600mg
Ac:etmninaphen ~1000mg q~h PO 4000mgld Avoid in liver disease and
giiJCOSH.phospham deficiency.
lbuprofer1 200-400 q~h PO 3200mg Avoid in renal insufficiency.
Naproxen 250-500mg q12 PO 1000mg
Cetewib 400 mg initial; 200 mg q12h PO 800mg Avoid in renal insufficiency.
Tramadol 50-lOOmg q6h PO 400mg Lower dosing in renal and
hepatic disease
Gabapenlin 600 mg initial; 300 mg q8h PO 2400mg
Ketorolac 15mg q~h IMIIV <65 yr, 90 mg; >65 yr, 60 mg Avoid in renal insufficiency.

Table 9 Narcotic Dosage Comparison Chronic Pain

• Patients with chronic pain can be expected to have higher
Dose (mg) analgesic requirements after surgery.
Drug Oral Parenteral • These patients are tolerant to the effects of opioids and tend
Fentanyl 0.1 to have very low thresholds for pain.
Meperidine 300 100 • Plans for pain management, in consultation between the
Morphine 30 10 surgeon, anesthesiologist, and patient, should be made preop-
Hydromorphone 7.5 1.5 eratively to optimally manage this acute-on-chronic pain
Methadone 20 10 state.
Tramadol 100 • The patient's chronic narcotic therapy should be continued
Codeine 200 130 and increased 30% to 40%, depending on the expected sever-
Oxycodone 25 15
ity of the postoperative pain.
• Multimodal analgesia should be implemented before the
The primary goal is to avoid hyperalgesia, allodynia, and • Continuous peripheral nerve blocks are critical in the treat-
increased pain. ment of this population of patients.
• Acetaminophen is a weak analgesic, but it should be given • Reasonable expectations for analgesia should be discussed
preoperatively and postoperatively (1 g every 8 hours) unless by the care team with the patient, and the goal for pain con-
contraindicated. trol should be to reach his or her average pain score.
The drug acts on prostaglandin synthesis centrally, so The concept of pain as the "fifth vital sign" (postopera-
there are no concerns with hyper- or hypo-coagulation side tive pain score of 3 or less out of 10) will not apply to these
effects perioperatively. patients.
• Celecoxib is currently the only available cyclooxygenase in-
hibitor available for clinical use. INFORMED CONSENT
It is an ideal nonsteroidal anti-inflammatory as it has no • The anesthesiologist must separately articulate both the
platelet and few gastrointestinal effects. risks and benefits of regional and general anesthetic options.
Caution should be exercised with chronic administration: Patients are most often accepting of a regional technique
strokes and myocardial infarctions have been reported after once it has been explained properly and they understand the
18 months of regular use. benefits of superior pain management and the avoidance of
• Gabapentin has been shown to reduce pain and analgesic re- postoperative nausea and vomiting.
quirements when given preoperatively. • The patient may make the fmal decision, but it is important
The drug is an N-methyl-n-aspartic acid antagonist, and for the surgical and anesthesia staff to recommend techniques
it reduces hyperexcitability of dorsal hom neurons induced associated with positive outcomes.
by tissue trauma. • The clinical impression is that regional anesthesia is safer
Gabapentin is active only where there is tissue trauma and than general anesthesia.
sensitization of nociceptive pathways, which distinguishes it Numerous studies have examined the complication rate
from other analgesics. for general and regional anesthesia.
Mild side effects include slight dizziness and somnolence. These studies have compared long-term outcomes between
both techniques and have found no difference between re-
Multimodal Analgesia Perioperative Pain Control gional and general anesthesia in terms of nonfatal myocar-
• Table 9 covers equianalgesic dosages of opioids. dial infarction, unstable angina, or 6-month mortality.
• Table 10 summarizes multimodal postoperative pain con- This is reassuring, but there are other outcomes important
trol methods. when choosing an anesthetic plan.

Table 10 Multlmodal Postoperative Pain Management

Drug Mild Postoperative Pain Moderate Postoperative Pain Severe Postoperative Pain
Acetaminophen Preop: 1000 mg Preop: 1000 mg Preop: 1000 mg
Postop: 1000 mg q8h Postop: 1000 mg q8h Postop: 1000 mg q8h
Celecoxib Preop: 400 mg Preop: 400 mg Preop: 400 mg
Postop: 200 mg q12h Postop: 200 mg q12h Postop: 200 mg q12h
Gabapentin 600mg 600 mg/300 mg q8h
Oxycodone SR
Pt <65 yr Preop: 10 mg Preop: 20 mg
Postop: 10 mg q12h Postop: 20 mg q12h
Pt >65 yr Preop: 10 mg
Postop: 10 mg q12h
Oxycodone IR Assess pain score (Q-1 O) Assess pain score (Q-10)
4 or 5: 5 mg q4h 4 or 5: 5 mg q2h
6-10: 10 mg q4h 6-10: 10 mg q2h

COMPLICATIONS Postoperative Nausea and

General Anesthesia Table 11 Vomiting Prophylaxis and
• The perceived efficiencies of general anesthesia may not be Treatment
evident in the postoperative period where more complications
must be managed, and the level of postoperative care with gen- Factors
eral anesthesia will be dictated by these complications.
Premenopausal female
Postoperative Nausea and Vomiting History of motion siclcness
History of PONV
• Avoiding postoperative nausea and vomiting (PONV) is a Nonsmoker
high priority because of the expense resulting from treatments Surgical
and subsequent delays. Laparoscopidlaparotomy
PONV may not respond to treatment, leading to an un- Plastic surgery
planned hospital admission. Otolaryngology
Patient satisfaction surveys have determined that patients Strabismus surgery
often find PONV more unpleasant than postoperative pain. Treatment
• Postoperative nausea and vomiting risk is related to age. Monitored anesthesia care or regional anesthesia
No treatment required
There is a low risk in children less than 2 years old, but
Two factors
the risk increases until puberty and then drops as aging
Dexamethasone 8 mg at induction of anesthesia
occurs. Odansetron (Zofran) 4 mg at end of surge~y
• Patients with prior PONV or who have motion sickness Three or four factors
have a higher risk of PONV with general anesthesia. Dexamethasone 8 mg at Induction of anesthesia
Women have a higher incidence of PONV. Droperidol 0.625 mg at induction of anesthesia (Q-T interval less than
Nonsmokers have a higher risk of PONV. 440 msec)
• The risk of PONV varies with the type of surgery. Five factors
Ear, nose, and throat and dental procedures have a high Dexamethasone 8 mg at Induction of anesthesia
incidence of PONV, followed by orthopaedic and plastic Droperidol 0.625 mg at induction of anesthesia (Q-T interval less than
440 msec)
Odansetron (Zofran) 4 mg at end of surgery
Procedures such as strabismus, peritoneal, testicular, and Total intravenous anesthesia with propofol
middle ear surgeries are associated with PONV.
• The risk of PONV is higher with general anesthesia than re-
gional anesthesia.
General anesthetics such as the inhalational gasses (ni-
trous oxide, sevoflurane, and desflurane) increase the inci- The symptoms of corneal abrasion include redness, tear-
dence of PONV compared to propofol. ing, photophobia, decreased visual acuity, and pain.
• Droperidol (0.625 mg) has been a PONV treatment main- They are usually self-limited, resolving in 24 to 48 hours,
stay because of its efficacy and low cost. and artificial tears and an eye patch are standard treatments.
However, as a result of isolated cardiac events with large Severe abrasions may warrant ophthalmologic consulta-
doses of droperidol (1.25 to 2.5 mg) in the presence of tion as they may lead to cataract formation.
prolonged Q-T syndrome, the U.S. Food and Drug • Pharyngeal injuries
Administration has issued a black box warning for its clini- Endotracheal intubation may cause a sore throat in 20%
cal use. to 50% of patients, depending on the amount of trauma
• Table 11 summarizes factors related to patient and surgery during laryngoscopy or oropharyngeal suctioning.
and lists treatment guidelines. Local anesthetic ointments during anesthesia, once
thought to prevent sore throats, may also result in airway
Urine Retention
irritation. This may present as pain or as unquenchable
• Voiding difficulty is common after spinal anesthesia and in thirst.
patients with prostatic hypertrophy as well as in urology, in- Mucosal trauma may also be the result of the laryngeal
guinal hernia, and genital procedures. mask airway, despite the impression that they are less inva-
• The use of parenteral opioids to control significant pain will sive and traumatic than endotracheal tubes.
increase the incidence of urine retention. Dental damage may occur during the induction or emer-
• For procedures associated with a low risk of urine retention, gence from anesthesia.
patients may be discharged without demonstration of voiding. Any dental damage should be carefully documented,
• Patients must be instructed to return for evaluation if they and dental consultation may be needed depending on the
have not voided in a specified time frame. extent of the injury.
Lip, gum, or tongue damage may be treated with ice to
Postanesthetic Injuries manage the pain and inflammation.
• Corneal abrasion • Nerve injuries
Corneal abrasion may occur due to drying of the cornea Nerve injuries may occur during general anesthesia from
or incidental trauma during mask ventilation or intubation improper positioning and padding during the procedure.
or as a result of the patient rubbing the eyes after the Injury may occur from compression or stretch of the
procedure. neural tissue.

Nerve injury is usually thought to be associated with re- gram-negative bacillus (21.6%), and Staphylococcus aureus
gional anesthesia, but the incidence of nerve injury is higher (17.6%).
with general anesthesia (ulnar nerve). • Localized inflammation or infection at the site is associated
with factors such as catheter duration greater than 48 hours,
Regional Anesthesia male sex, absence of antibiotic prophylaxis, and postoperative
monitoring in the intensive care unit. 4
Nerve Injury
It is our practice to limit the peripheral nerve catheter and
• The incidence of nerve injury was evaluated in a large retro- infusion to 48 hours.
spective European study involving over 150,000 regional Catheters are tunneled under the skin for prolonged anal-
anesthetics.1 gesia, preventing bacteria from migrating to deeper tissue
The anesthetks were administered over a 1 0-month pe- planes.
riod; over 50,000 were peripheral nerve blocks. The inci-
dence of peripheral nerve injury was 0.04% (4/10,000). Hemorrhagic Complications
Peripheral nerve injury occurred in 12 patients, and the • The risk of bleeding during regional anesthesia, although
symptoms were present after 6 months in 7 patients. rare, is always present because of the anatomic relationships of
Much has been written about the risks of nerve injury nerves and vascular structures.
after peripheral nerve blocks, but it is only recently that the • Hematoma formation has been reported with almost every
positive merits of these techniques have been discussed. nerve block approach, and superficial bruising is very common.
• Peripheral nerve injury with regional anesthesia may be the • A high index of suspicion will allow early diagnosis and
result of direct needle or catheter trauma, local anesthetic tox- treatment, avoiding permanent injury.
icity, or vasoconstrktors added to the local solution. • Patients at particularly high risk for hemorrhagic complica-
• Severe injuries occurred, in adult patients under general tions are those receiving low-molecular-weight heparins, an-
anesthesia, when local anesthetic was inadvertently injected tiplatelet drugs such as dopidogrel (Plavix), therapeutic
into the spinal cord. This resulted in irreversible paralysis.2 Coumadin levels, and antithrombolytic drugs.
• Short-beveled needles do not result in fewer cases of nerve • Hematomas should be considered in the setting of an evolv-
injury compared with long-beveled needles, as had previously ing neural deficit and obviously if vascular injury occurred
been believed. during the technique.
The neural repair appears more rapid after injury from a • Acute hematoma formation may be handled conservatively
long-beveled needle according to animal data, although by holding pressure for at least 5 minutes and continued ob-
there are no clinkal data to support this. servation.
• Patient factors increasing the risk of nerve injury include dia- • A large hematoma that continues to expand or is causing
betes mellitus, pre-existing nerve injury, male sex, and older age. acute neural deficits will require surgical drainage to preserve
• Surgical factors associated with a higher rate of nerve injury nerve function.
include trauma, stretch, positioning, tourniquet ischemia, and Imaging such as ultrasound or CT scanning may confirm
cast compression. the diagnosis before surgery if there is doubt.
• Neurologic changes should be evaluated urgently so that
treatable causes such as hematoma, constrictive dressings, and Local Anesthetic Toxicity
abscess formation may be diagnosed and treated, limiting the • Local anesthetics in the proper concentration and dosage are
extent of injury. safe. When local anesthesia is inadvertently injected intravas-
• If significant nerve injury is suspected, documentation of cularly, seizures may occur.
neurologic status and neurology consultation with early and • Seizures result due to high concentration of local anesthesia
late electromyography are advisable. in the plasma despite binding by albumin and alpha-1 acid gly-
Infectious Complications
• The seizures tend to be short with the prompt administra-
• Infection may result after a nerve block from the contami- tion of benzodiazepines and positive-pressure ventilation.
nation of the needle or local anesthetics as well as from • When a significant portion of a bupivacaine dose becomes
bacteremia. intravascular, death has occurred as a result of the cardiac
This would be less likely with a single injection block be- conduction being blocked, which resulted in cardiovascular
cause the local anesthetics used in regional anesthesia are bac- collapse.
tericidal (bupivacaine at a concentration of at least 0.25%). • Factors affecting toxicity of local anesthetics
Infection is more likely with a continuous block as the Location of block (intercostal, epidural, or interscalene)
catheter is a track for bacteria and dilute local anesthetics Patient characteristks (extremes of age, parturients,
are less bactericidal. hypoalbuminemia)
Local infection at the site of the block is a clear contraindi- Pharmacologic factors
cation to a regional anesthetic, especially catheter placement. • Toxicity: bupivacaine> ropivacaine >> mepivacaine>>
• Bacterial colonization of continuous nerve blocks was ex- lidocaine
amined by Capdevila et al.4
In the 969 catheters that were cultured, bacterial coloniza- Perioperative Considerations
tion was found to be present in 28.7% (278), but only 3% of • The proper selection of anesthetic techniques for orthopaedic
the patients had signs of local inflammation at the site. surgery begins with the consideration of surgkal and patient
The bacteria most often identified were coagulase- factors. Additionally, factors such as safety, cost-effectiveness,
negative staphylococci (Staphylococcus epidermidis; 61 %), and efficiency are considered.

• A well-organized surgi~al and anesthetk pra~ti~e allows pa- report of 100 consecutive cases. J Shoulder Elbow SUig 2000;9:
tients to receive nerve blocks before going to the operating 268-274.
7. Del Rincon ID, Williams K, Stern MP, et al. High incidence of cardio-
vascular events in a rheumatoid arthritis cohort not explained by tta-
Peripheral nerve blocks need not delay surgery or fail if ditional cardiac risk factors. Arthritis Rheum 2001;44:2737-2745.
proper utilization of the indu~on room o~~urs. 8. Hadzic A, Arliss j, Kerim.oglu B, et a!. A comparison of infraclavicu-
Operating room efficiency and turnover are increased in lar nerve block versus general anesthesia for hand and wrist day-case
this manner. The patient will be sedated and have monitors, sUigeries. Anesthesiology 2004;101:127-132.
intravenous a~cess, and a fun~tional regional block in pla~e 9. Hall Mj, Lawrence L Ambulatory sUigery in the United States, 1996.
when he or she enters the operating room. Adv Data 1998;300:1-16.
10. Ilfeld BM, Morey TE, Enneking FK. Continuous infraclavicular
• The regional patient will also bypass the postanesthesia ~are brachial plexus block for postoperative pain control at home: a ran-
unit and may move to the outpatient or regular nursing area domized, double-blinded, placebo-controlled study. Anesthesiology
without delay. 2002;96:1297-1304.
The upper extremity is uniquely suited for regional anes- 11. Ilfeld BM, Morey TE, Wright lW, et a!. Continuous inrerscalene
thesia because the bradial plexus may be anesthetized with brachial plexus block for postoperative pain control at home: a ran-
one injection, and ~ontinuous blo~ks may be maintained domized, double-blinded, placebo-controlled study. Anesth Analg
2003;96:1089-1 095.
postoperatively, providing extended analgesia. 12. Klein SM, Bergh A, Steele S. Thoracic paraverrebral block for breast
• Whether general, regional, or a oombination is selected for sUigery. Anesth Analg 2000;90:1402-1405.
anesthesia, patients' perioperative experien~es are improving. 13. Klein SM, Grant SA, Greengrass RA, et al. lnterscalene brachial
In the past, regional anesthesia was selected for safety rea- plexus block with a continuous catheter insertion system and a dis-
sons, and now regional anesthesia is being administered for posable infusion pump. Anesth Analg 2000;91:1473-1478.
its superior pain ~ontrol. 14. Klein SM, Nielson KC, Greengrass R. Ambulatory discharge after
long-acting peripheral nerve blockade. Ancsth Analg 2002;94:65-70.
In the future, anesthetics may be sele~ted based on the
15. Larson S, Lundberg D. A prospective survey of nausea and vomiting.
patient's genotype, and the patient may have surgery and Act Anesth Scand 1995;39:539-545.
postoperative pain ~ontrol without needles, catheters, or 16. Lee LA, Domino KB, Caplan RA. Complications associated with pe-
even a general anesthesia. Until then, regional tedniques, ripheral nerve blocks: lessons From the ASA Closed Claims Project.
in ~onjun~tion with multimodal analgesi~ protocols, Anesthesiology 2004;101:143-152.
will ~ontinue to be the ~are standard after orthopaedk 17. Maione S, Valentini G, Giunta A, et al. Cardiac involvement in
surgery. rheumatoid arthritis: an echocardiographic study. Cardiology 1993;
18. McNedy JK, Farber NE, Rusy LM, et al. Epidural analgesia improves
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2. Benumof JL. Permanent loss of cervical spinal cord function associ- tality with disease severity in rheumatoid arthritis, independent of co-
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Anesthesiology 2000;93:1541-1544. 20. Ong CK, Lirk P, Seymour RA, et al. 1hc efficacy of preemptive anal-
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4. Capdevila X, Pirat P, BriDguier S, et al. Continuous peripheral nerve 21. Rosenblatt MA, Abd M, Fischer GW, et al. Successful usc of a 20%
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plications in 1,416 patients. Anesthesiology 2005;103:1035-1045. 22. Tobias JD. Continuous femoral nerve block to provide analgesia fol-
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- Arthroscopy of the Hand
Chapter 3 and Wrist
-------------------------------------------. ---------------------------------------------------------------~
t David J. Slutsky

BACKGROUND The 3-4 portal is named for the interval between the third
dorsal extensor compartment, which contains the extensor
• Since its inception. wrist arthroscopy has continued to evolve.
The initial emphasis on viewing the wrist from the dorsal aspea pollicis longus tendon, and the fourth extensor compart-
ment, which contains the extensor digitorum commwtis
arose from the relative lack of neurovascular structures as well
(EDC) tendons.
as the familiarity of most surgwns with dorsal approaches to
The ~5 portal is located between the EDC and the exten-
the radiocarpal joint.
sor digiti minimi (EDM).
• Anatomic studies provided a better wtderstanding of both
The 6R portal is located on the radial side of the extensor
the interosseous ligaments as well as carpal kinematics, which
carpi ulnaris (E.CU) tendon; the 6U portal is located on the
led to the development of midcarpal arthroscopy.
ulnar side.
• Innovative surgeons continue to push the envelope through
• The midcarpal joint is assessed through two portals,
the development of techniques for treating intracarpal pathol-
which allows triangulation of the arthroscope and the instru-
ogy, which in tum has culminated in a plethora of new acces-
sory portals. mentation.
The midcarpal radial portal is located 1 em distal to the
3-4 portal and is bowtded radially by the extensor carpi
ANATOMY radialis brevis and ulnarly by the EDC.
• The standard portals for wrist arthroscopy are dorsal The midcarpal ulnar portal is similarly located 1 to 2 em
(RG 1A-C). This is in part due to the relative lack of neurovas· distal to the ~5 portal and is bowtded by the EDC and
cular structures an the dorsum of the wrist as weD as the initial the EDM.
emphasis on assessing the volar wrist ligaments. The dorsal por- • The triquetrohamate portal enters the midcarpal joint at the
tals that allow access to the radiocarpal joint are so named in re- level of the triquetrohamate joint ulnar to the E.CU tendon.
lation to the tendons of the dorsal extensor compartments. The entry site is both ulnar and distal to the midcarpal ulnar
The 1-2 portal lies between the first extensor compart· portal. Branches of the dorsal cutaneous branch of the ulnar
meat tendons, which include the extensor pollicis brevis and nerve are most at risk (FIG ZA).
the abductor pollicis longus, and the second extensor com- • The dorsal radioulnar joint portal lies between the E.CU and
partment, which contains the extensor carpi radialis brevis the E.DM tendons. Transverse branches of the dorsal
and longus (FIG 1D). cutaneous branch of the ulnar nerve are the only sensory


FIG 1 • Dorsal portal anatomy. A. Cadaver dissection of the dorsal aspect of a left wrist demon-
strating the relative positions of the dorsoradial portals. EDC, extensor digitorum communis; EPI.,
extensor pollicis longus; SRN, superficial radial nerve;*, tubercle of Lister. B. Relative positions of
the dorsoulnar portals. EDM, extensor digiti minimi; DCBUN, dorsal cutaneous branch of the
ulnar nerve. (continued)


FIG 1 • (continued) C. Positions of the 6R and 6U portals.

D. Branches of the superficial radial nerve (SRN). SR1,
minor dorsal branch; SR2, major dorsal branch; SR3, major
palmar branch. (From Slutsky DJ. Wrist arthroscopy portals.
In Slutsky OJ, Nagle DJ, eds. Techniques in Hand and Wrist
c Arthroscopy. Philadelphia: Elsevier, 2007.)

FIG 2 • A. Ulnar aspect of a left wrist demonstrating the relative positions of the triquetrohamate (T-H) portal and
the 6U portal. DCSUN, dorsal cutaneous branch of the ulnar nerve; UN, ulnar nerve. B,C. Dorsal distal radioulnar
joint (DRUJ) portal anatomy. B. Relative position of the proximal (PORUJ) and distal (OORUJ) portals. C. Close-up with
the dorsal capsule removed demonstrating the position of the needles in relation to the dorsal radioulnar ligament(*).
AD, articular disc; UC, ulnocarpal joint; UH, ulnar head. D,E. Volar ORUJ portals. D. Volar aspect of a left wrist
demonstrating the relative positions of the volar ulnar (VU} and volar ORUJ (VOIQ portals in relation to the ulnar nerve
(*) and ulnar artery (UA}. FDS, flexor digitorum sublimis; FCU, flexor carpi ulnaris. E. aose-up view after the volar
capsule is removed showing position of needles in relation to the volar radioulnar ligament (*}. Tr, triquetrum; UH,
ulnar head. (From Slutsky OJ. Wrist arthroscopy portals. In Slutsky DJ, Nagle DJ, eds. Techniques in Hand and Wrist
Arthroscopy. Philadelphia: Elsevier, 2007.)

nerves in proximity to the dorsal radioulnar portal. at a mean volar distal radioulnar portal lies 5 mm to 1 em proximal to
of 17.5 mm distally (range 10-20 mm) (FIG 2B.C). the ulnocarpal entry point (FIG 2D.E).
• There are two volar portals that can be used to access the ra-
diocarpal joint. AUTHOR'S EXPERIENCE
The volar radial portal is accessed through the floor of the • The volar radial portal has been used in 111 patients since
flexor carpi radialis tendon sheath at the level of the proxi- 1998.4
mal wrist crease.5•7 ,9 Additional pathology was evident in 61 of the patients
Anatomic studies revealed that there is a safe zone free that was not visible from any standard dorsal portals. This
of any neurovascular structures, equal to the width of included 1 case of hypertrophic synovitis of the dorsal cap-
the flexor carpi radialis tendon plus at least 3 mm in all sule (FIG 3A), 1 patient with an avulsion of the ra-
directions. dioscapholunate ligament that exposed the volar scapholu-
The volar aspect of the midcarpal can be accessed nate deft (FIG 38), 2 patients with tears restricted to the
through the volar radial midcarpal portal. The same skin palmar region of the acapholunate interosseous ligament
incision is used but the capsular entry point is about 1 em (SLIT.), and 57 patients with tears of the dorsal radiocarpal
distal. ligament (DRCL). In 16 patients an isolated DRCL tear
The volar ulnar portal is located underneath the ulnar alone was responsible for chronic dorsal wrist pain (FIG
border of the flexor tendons at the level of the proximal 3C,D).
wrist crease.6 The midcarpal was accessed from the volar radial
• The volar aspect of the distal radioulnar joint (DRUJ) can portal in three cases. In one patient with Preiser disease, the
be accessed through the volar distal radioulnar portal using use of the volar radial midcarpal portal allowed a more com-
the same skin incision, but the capsular entry point for the plete assessment of the distal articular surface of the






Radius Radius

FIG 3 • A. Hypertrophic synovitis (*} of the dorsal capsule in a case of Presier disease as seen through
the volar radial portal. B. Radioscapholunate ligament avulsion. Note unmasking of the palmar cleft (*)
between the scaphoid and lunate. SUL, scapholunate interosseous ligament; RSL, radioscapholunate
ligament. C.D. Volar radial portal view. C. Normal dorsal radiocarpal ligament. Hook probe is inserted
through the 3-4 portal. SUL, scapholunate interosseous ligament; DRCL, dorsal radiocarpal ligament.
D. DRQ. tear (*}. Hook probe inserted through the 3-4 portal. (continued)
25 -


E F~
FIG 3 • (continued) Volar midcarpal portal. E. Chondromalacia of the palmar capitate (C). Probe is in the
midcarpal radial portal (MCR). L. lunate. F. Tear of the palmar region of the scapholunate interosseous
ligament (SLIL), as viewed from the volar radial midcarpal portal. Note the intact dorsal fibers of the SLIL
S, scaphoid; L, lunate; H, hamate; DC, dorsal capsule. (A,B: From Slutsky OJ. Wrist arthroscopy through a
volar radial portal. Arthroscopy 2002;18:62~30, with permission.)

scaphoid. Another patient had unrecognized chondromalacia The ulnar-sided pathology included 21 tears of the lunotri-
of the palmar capitate following a perilunate dislocation quetral interosseous ligament (Lm) (FIG 4A), 19 triangular
(FIG 3E). The volar radial midcarpal portal admirably fibrocartilage complex (TFCC) tears, and 2 ulnolunate liga-
demonstrated the intact dorsal portion of the SLIL in the pa- ment tears. In one patient a TFCC tear was found to extend
tient with the palmar tear (FIG 3F). into the dorsoulnar ligament (FIG 48,C). The volar ulnar
• The volar ulnar portal has b"n used in 61 patients since portal facilitated debridement of the palmar region of the
1998.8 Lm ligament through the 6R or 6U portals. In three of these


FIG 4 • A. Lunotriquetral ligament tear as viewed

from the volar ulnar portal. Note the tear of the
lunotriquetralligament (*). T, triquetrum, L, lu-
nate. B,C. Volar ulnar portal view. B. Triangular fi-
brocartilage (TFQ tear extending into the dorsal ra-
dioulnar ligament. Probe inserted through 1he dor-
sal 4-5 portal. C. Palpation of the dorsal radioulnar
ligament tear with the hook probe. (continued)


AG 4 • (continued) D. Unsuspected region of chondromala-

cia on palmar surface of the lunate. L, lunate; T, triquetrum.
E. View of a loose body (-) in the ulnocarpal joint looking
across the joint from the volar radial portal. TFC, triangular
fibrocartilage; T, triquetrum. F. View from the palmar distal
radioulnar joint portal. The undersurface of the articular disc
demonstrates a tear of the triangular fibrocartilage (TFQ
along widl synovitis (•}. G,H. Views from the volar distal
radioulnar portal. G. View of the sigmoid notch from the
palmar aspect of the wrist. AD, articular disc; DC. dorsal
distal radioulnar joint capsule; UH, ulnar head. H. View of
an intact foveal attachment. Probe is in the distal dorsal
radioulnar joint portal (DDRUJ). PRUL, palmar radioulnar
ulnar dome ligament; DRUL, dorsal radioulnar ligament. (B,C: From
Slutsky OJ. The use of a volar ulnar portal in wrist
H arthroscopy. Arthroscopy 2004;20:15Pr163, with permission.)

patients WU"eCoguized chondromalacia of the palmar aspea has not responded to an appropriate trial of conservative
of the lunate was identified (FIG 40), and one patient had measures:
chondromalacia of the palmar triquetrum. One patient was Nonsteroidal anti-inflammatories and activity modification
found to have a loose body in the ulnocarpal joint (FIG 4E). Cortisone injection
The volar aspect of the DRUJ was accessed in eight of • Wrist arthroscopy is used as an adjuvant procedure for the
these patients to rule out a peripheral TFCC tear. The DRUJ treatment of acute fractures of the distal radius or scaphoid, or
was well visualized. demonstrating an intact articular disc in for staging degenerative disorders involving the carpus.
four and a full-thickness tear with undersurface fibrillation
in one (FIG 4f). The foveal attachment of the TFCC was Indications
seen to be intact in each case (FIG 4G.H). • The indications for the use of the standard dorsal portals are
intertwined with the indications for wrist arthroscopy and
depend largely on the condition that is being treated.
NONOPERATIVE MANAGEMENT A typical arthroscopic e:xamination of the wrist will include
• In general, wrist arthroscopy is indicated as a diagnostic variable combinations of the 3-4 portal, the 4-5 portal. and
technique in any patient with persistent wrist pain that the 6R and 6U portals.

The 3-4 and 4-5 portals are the main viewing portals • The dorsal DRUJ portals may be used in concert with the
for the radial aspect of the radiocarpal joint and for instru- volar distal radioulnar portal to more completely assess the
mentation. status of the articular cartilage of the ulnar head and sigmoid
The 4-5 and 6R portals are used to access the ulnocarpal notch as well as for instrumentation.
joint. • The number of conditions amenable to arthroscopic treat-
The 6U portal is typically used for outflow. ment continues to grow. Many arthroscopic procedures are
• The volar radial portal is indicated for the evaluation of the now common, while others await clinical validation. Table 1
DRCL and the pahnar portion of the SLIL. The volar radial provides a list of the more standard procedures.
portal also facilitates arthroscopic reduction of intra-articular
fractures of the distal radius fractures by providing a clear
view of the dorsal rim fragments. • Contraindications to the use of dorsal or volar portals would
• The volar ulnar portal is indicated for visualizing and include marked swelling, which distorts the topographic
debriding palmar tears of the lunotriquetral ligament. It also anatomy; large capsular tears, which might lead to extravasa-
aids in the repair or debridement of dorsally located TFCC tion of irrigation fluid; neurovascular compromise; bleeding
tears since the proximity of the 4-5 and 6R portals makes tri- disorders; or infection.
angulation of the instruments difficult. • Unfamiliarity with the regional anatomy is a relative con-
• Midcarpal arthroscopy through the dorsal midcarpal por- traindication.
tals is essential in making the diagnoses of scapholunate and
lunotriquetral instability. SURGICAL MANAGEMENT
The grading scale reported by Geissler and colleagues2 • It is useful to have a systematic approach to viewing the wrist.
provides a means for staging the degree of instability and • The structures that should be visualized as a part of a stan-
provides an algorithm for treatment. dard examination include the radius articular surface; the
Midcarpal arthroscopy is likewise employed for the as- proximal scaphoid, lunate, and triquetrum; the SLIL and
sessment and treatment of chondral lesions of the proximal Lill, both palmar and dorsal; the radioscaphocapitate liga-
hamate. ment; the long radiolunate ligament; the radioscapholunate
The triquetrohamate joint can also be accessed through ligament; the ulnolunate ligament; the ulnotriquetral liga-
another special-use midcarpal portal. 1 ment; the articular disc; and the radial and peripheral TFCC
• The volar radial midcarpal portal is occasionally used as an attachments.
accessory portal for visualizing the palmar aspects of the cap- • It is my practice to establish the dorsal portals first but then
itate and hamate in cases of avascular necrosis or osteochon- to start the arthroscopic examination with the volar radial
dral injury. portal to visualize the palmar SLIL and the DRCL ligament to
This portal facilitates visualization of the pahnar aspect of minimize any error from iatrogenic trauma to the dorsal cap-
the capitohamate interosseous ligament, which is important sular structures.
in minimizing translational motion and has an essential role • In patients with ulnar-sided wrist pain, the volar ulnar por-
in providing stability to the transverse carpal arch. tal is used to assess the palmar Lill and dorsal radioulnar lig-
• The volar distal radioulnar portal is useful for assessing the ament, the region of the extensor carpi ulnaris subsheath, and
deep foveal attachment of the TFCC, which would normally the radial TFCC attachment.
require an open capsulotomy. The scope is then inserted in the 3-4 portal followed by
It may be employed if the suspicion of a peripheral TFCC various combinations of the 4-5 portal and 6R portal. The
detachment remains despite the absence of any visible TFCC 6U portal is mostly used for outflow, but it may be used for
tears through the standard ulnocarpal portals. instrumentation when debriding palmar Lill tears.
• Midcarpal arthroscopy is then performed to probe the
SLll. and LTIL joint spaces for instability, the capitoha-
mate interosseous ligament, and to look for chondral lesions
on the proximal capitate and hamate and loose bodies
(FIG 5 ).
Table 1 Arthroscopic Wrist Procedures The special-use portals such as the dorsal and volar DRUJ
portals and the 1-2 portal are used as needed.
Ganglion resection: volar and dorsal
Release of wrist contracture Preoperative Planning
Arthroscopic synovectomy • A 2.7-mm, 30-degree-angled scope along with a camera at-
Staging of degenerative arlhritis (scapholunate advanced collapse or tachment is used.
scaphoid nonunion advanced collapse, Kienbock disease) Table 2 describes the typical field of view as seen through
Radial scyloidectDmy a 2.7-mm arthroscope under ideal conditions. 1•4
Proximal pole of hamate resection
Dorsal radiocarpal ligament repair
A 1.9-mm scope is sometimes beneficial, especially for
Evaluation and treatment of carpal instability: scapholunate, loootrique- evaluation of the DRUJ.
tral, midcarpal • A fiberoptic light source, video monitor, and printer have
Triangular fibrocartiage tears: repair vs. debridement become the standard of care.
Arthroscopic wafer resection • Digital systems allow direct writing to a CD and superior
Arthroscopic reduction and internal fixation of distal radius fractures video quality as compared to analog cameras.
Arthroscopic-guided fixation of scaphoid fractures • A 3-mm hook probe is needed for palpation of intracarpal

(Conmed-Linvatec Corporation, Largo, FL). Ligament re-

pairs can also be facilitated by use of a Tuohy needle, which
is generally found in any anesthesia cart.
• The patient is positioned supine on the operating table with
the involved arm abducted on an arm table.
• A tourniquet is placed as far proximal on the ann as feasible.
• Traction is useful:
A shoulder holder along with 5- to 10-lb sand ba~ at-
tached to an arm sling
A commercially available traction tower such as the
Linvat~ tower (Cowne~Linvatec Corporation, Utica, NY)
or the ARC traction tower (Arc Surgical LLC, Hillsboro, OR)
• For the dorsal portals the surgeon faces the dorsum of the
wrist and is seated by the patient's head. For the volar portals
FIG 5 • Chondromalacia (*} on the proximal pole of the hamate the surgeon faces the palm and is seated in the patient's axil-
(H}. C, capitate; L, lunate; T, triquetrum. lary region.

• A motorized shaver or diathermy unit such as the Approach

Oratec probe (Smith &:: Nephew, NY) is useful for debridement. • Portals are established by palpating and identifying
• Ancillary equipment is largely procedure-dependent. anatomic landmarks and then inserting a 22-gauge needle into
A motorized 2.9-mm burr is needed for bony resection. the joint space. The joint is then inj&:ted with 5 c:c of saline.
There are a variety of commercially available suture The ability to draw the saline back into the syringe serves as
repair kits, including the 1FCC repair kit by Linvat~ evidence that the needle is in the joint.

Table 2 Field of View

Portal Radial Central Volar Donal /Distal Ulnar

1-2 Scaphoid Sid lunate Proximal Sid radial Oblique views of Oblique vil!ws TFCC poorly visualized
fossa, dorsal rim of scaphoid, proximal RSC, LRL., SRL ofDRCL
radius lunate
3-4 Scaphoid and lunate Proximal scllflhoid and RSC, RSL. LRL. ULL Oblique vil!ws of the TFCC radial insertion, central
fossa, volar rim of lunate, dorsal and DRCL inseftion onto disc, ulnar attachment,. PRUL,
radius membranous SLIL the dorsal SLIL DRUL, PSO, PTR
Lunate fossa, val• Proximal lunate, RSL, LRL, ULL Poorly seen TFCC radial insertion, central
rim of radius triquetrum, dorsal and disc, ulnar attachment,. PRUL,
membranous LTIL DRUL, PSO, PTR
6R Poorly seen Proximal lunate, ULL, ULT Poorly seen TFCC radial insertion, central
triquetrum, dorsal and disc, ulnar attachment,. PRUL,
membranous LTIL DRUL, PSO, PTR
6U Sigmoid notch Proximal triquetrum, Oblique views of Oblique vil!ws TFCC oblique views of the
membranous LTIL ULL, ULT ofDRCL radial insaiion, central disc,
ulnar attachment. PRUL, DRUL
Valar radial Scaphoid Sid lunate Scaphoid and lunate Palmar scaphoid and Oblique vil!ws of Oblique views of the radial
fossa, dorsal rim of fossa. diii'SIII rim of lunate, palm• SLIL RSL., LRL., ULL insertion, central disc, ulnar
radius radius attad!ment. PRUL, DRUL
Midcarpal radial Scaphotrapezotrape- SLIL joint,. distal Radial limb of arcuate Proximal CiPitate, LTIL joint,. partial triquetrum
zoidal joint. distal scaphoid. distal lunate ligament Oe, continua- CHIL, oblique vil!ws
scaphoid pole tion of the RSC ligament) of proximal hamate
Midcarpal ulnar Distal articular surface SLILjoint Volar limb of a~cuate Oblique vil!ws of LTIL joint,. triquetrum
of the lunate and ligament Qe, continua- proximal CiPitate,
triquetrum and tion of the triquetro- CHIL, proximal
partial saphoid CiPitcHunate} hamate
Dorsal distal Sigmoid notch, radial Ulnar head Palmar radioulnar Proximal surface of Umited vit!W' of deep DRUL
radioulnar joint attadlment ofTFCC ligament articular disc
Valar distal Sigmoid notch, radial Ulnar head Dorsal radioulnar Proximal surface of Foveal attadlment of deep
radioulnar joint attadlment ofTFCC ligament articular disc fibefs of TFCC \te, DRUL.PRUL}

CHil, capll:oharnate ligament; DRCL, dorsal radlocarplllllgament; DRUl, clorsallllllolilllllr ligament; LR1. long rdohll!flte ligament; L'nl, ~notltq~llntero51iE'OijS ligament; PRUl, palmar
rdoulnar ligament; PSR. prestylold reoes1i; PTO, plso-1rfq~~etral ortfk:e; RSC, lllllosalphoa~pltllte ligament; RSL, rdoscaphc*lnrrte ligament; SUL, sc.aphohlllflte lrrtEfOSSEOIIS ligament; SRL,
short radlc*lnate ligament; 'IKC. trlllngular flbrocartllage complex; UU. ulnclul\flte ligament; ULT, utlotliJ~111111gament.
Adapted from SNtil(y DJ. Wrist arthi'OSGlpy portals.. In Sl\ltsl(y DJ, Nagle DJ, eels.. Tedmlq~~es In Hand and Wrtst Anhr05alPY. Phllallelphla: ElseWe!', 2007.

• Shallow incisions avoid injury to sensory nerve bran~hes • Routindy, an 18-gauge needle is pla~ed in the 6U portal for
and tendons. Soft tissues are diss&ted using a blunt mosquito outflow.
clamp or a pair of small ~urved scissors. The dorsal ~apsule • Synovitis, fra~tures, ligament tears, and a tight wrist joint
is pier~ed with these same instruments, providing a~ess to may limit the field of view and ne~essitate the use of more por-
the joint. tals to adequatdy assess the entire wrist.
• A blunt tro~ar is used to introdu~e the s~ope ~annula, whi~h
will house the s~ope and the inflow.

• The concavity overlying the lunate between the extensor • By rotating the scope dorsally while looking in an ulnar
pollicis longus and the EDC is located just distal to the direction, the insertion of the dorsal capsule onto the
tubercle of Lister, in line with the second web space. dorsal aspect of the SLIL can often be visualized. This is a
• The radiocarpal joint is identified with a 22-gauge nee- common origin for the stalk of a dorsal ganglion.
dle that is inserted 10 degrees palmar to account for the • The radioscapholunate ligament and the long radiolu-
volar inclination of the radius. nate ligament are radial to the portal and can be probed
• The vascular tuft of the radioscapholunate ligament is di- with a hook in the 4-5 portal .
rectly in line with this portal. Superior to the radioscapho- • The LTIL. TFCC. and ulnolunate ligament are ulnar to the
lunate ligament is the membranous portion of the SLIL. portal.

• The interval for the 4-5 portal is identified with the 22- • The ulnolunate ligament and the ulnotriquetral liga-
gauge needle between the EDC and EDM, in line with ment can be seen on the far end of the joint.
the ring metacarpal. • Proximally, the radial insertion of the TFCC blends imper-
• Because of the normal radial inclination of the distal ra- ceptibly with the sigmoid notch of the radius, but it can be
dius, this portal lies slightly proximal and about 1 em palpated with a hook probe in either the 3-4 or 6R portal.
ulnar to the 3-4 portal. • The peripheral insertion of the TFCC slopes upward into
• Care must be taken when inserting the scope since the the ulnar capsule. Peripheral TFCC tears are often lo-
LTIL lies directly ahead of this portal. cated ulnarly and dorsally.
• One encounters the ulnar half of the lunate when mov- • The palmar radioulnar ligament can be probed and visu-
ing the scope radially, and the oblique surface of the tri- alized (especially if torn), but the dorsal radioulnar liga-
quetrum in a superior and ulnar direction. ment is poorly seen.
• The LTIL is seen obliquely from this portal and is often • The pisotriquetral recess can sometimes be identified by
difficult to differentiate from the carpal bones without a small tuft of protruding synovium and when probed
probing, unless a tear is present. may yield views of the articular facet of the pisiform.

• The 6R portal is identified on the radial side of the ECU • The 6U portal is found on the ulnar side of the ECU
tendon, just distal to the ulnar head. tendon. Angling the needle distally and ulnar devia-
• The scope should be angled 10 degrees proximally to tion of the wrist helps avoid running into the tri-
avoid hitting the triquetrum. The TFCC is immediately quetrum.
below the entry site. • This portal can be used to view the dorsal rim of the
• The LTIL is located radially and superiorly, whereas the TFCC or for instrumentation when debriding the pal-
ulnar capsule is immediately adjacent to the scope. mar LTIL.

• The relevant landmarks in the snuff box are palpated should be no more than 4.5 mm dorsal to the first exten-
and outlined, including the distal edge of the radial sty- sor compartment and within 4.5 mm of the radial styloid
loid, the abductor pollicislongus, extensor pollicis brevis, ClEat FIG 1).10
and extensor pollicis longus tendons, and the radial • A blunt trocar and cannula are inserted with the wrist in
artery in the snuff box. ulnar deviation to minimize damage to the proximal
• To minimize the risk of injury to branches of the superfi- scaphoid.
cial radial nerve and the radial artery, the 1-2 portal

TEat AG 1 • Landmarks for the 1-2 por-

tal. A. cadaver dissection demonstrating
the placement of the 1-2 portal. SR, su-
perficial radial nerve branches; EPI., ex-
tensor pollicis longus; EPB, extensor pol-
l icis brevis; API.., abductor pollicis longus.
B. Surface landmarks for 1-2 portal. S,
scaphoid; ECRUB, extensor carpi radialis
longus and brevis. c. Superimposed
intra-articular field of view. (From
Slutsky OJ. Wrist arthroscopy portals.
In Slutsky OJ, Nagle OJ, eds. Techniques
in Hand and Wrist Arthroscopy.
Philadelphia: Elsevier, 2007.)


• The midcarpal radial portal is found 1 em distal to the Further ulnarly, the lunotriquetral articulation is vi-
3-4 portal. sualized.
• Flexing the wrist and firm thumb pressure helps identify • Moving the scope superiorly yields oblique views of the
the soft spot between the distal pole of the scaphoid proximal surface capitate and hamate as well as the capi-
and the proximal capitate. tohamate interosseous ligament.
• The scaphotrapezial trapezoidal joint lies radially and • The continuation of the radioscaphocapitate ligament,
can be seen by rotating the scope dorsally. which forms the radial arm of the arcuate ligament (ie,
• The scapholunate articulation can be seen proximally the scaphocapitate ligament) can occasionally be seen
and ulnarly; it can be probed for instability or step-off. across the midcarpal space.
• The midcarpal ulnar port is found 1 em distal to the seen as it crosses obliquely from the triquetrum, across
4-5 portal and 1.5 em ulnar and slightly proximal to the the proximal corner of the hamate to the pal mar neck of
midcarpal radial portal, in line with the ring metacarpal the capitate.
axis. • This is especially important in midcarpal instability.
• This entry site is at the intersection of the lunate, tri-
quetrum, hamate, and capitate with a type I lunate facet
• Normally there is very little ste~ff between the dis-
tal articular surfaces of the scaphoid and lunate.
and directly overthe lunotriquetral joint with a type Ill~ • Direct pressure from the scope combined with trac-
nate facet. 11 tion may force the carpal joints out of alignment.
• This portal provides preferential views of the lunotri- • The traction should be released and the scapholunate
quetral articulation. joint should be viewed with the scope in the midcarpal
• Directly anteriorly, the ulnar limb of the arcuate liga-
ment (ie, thetriquetro-hamate-capitate ligament} can be
ulnar portal, whereas the lunotriquetral joint should be
viewed with the scope in the midcarpal radial portal.


• A 2-cm transverse or longitudinal incision is made in the • A hook probe is inserted through the 3-4 portal and used
proximal wrist crease overlying the flexor carpi radialis to assess the palmar aspect of the SLIL and the DRQ..
tendon. The portal is established in the usual manner • A useful landmark when viewing from the volar radial
(IEat RG2}. portal is the intersulcal ridge between the scaphoid and
• It is not necessary to specifically identify the adjacent lunate fossae.
neurovascular structures, provided that the anatomic • The radial origin of the DRCL is seen immediately
landmarks are adhered to. ulnar to this, just proximal to the lunate.

1Eat FIG 2 • Technique for volar radial portal. A. Skin incision for volar ra-
dial portal. FCR, flexor carpi radialis tendon. B. Saline injection of radiocarpal
joint. C. Insertion of cannula through floor of the FCR sheath. (From Slutsky
c OJ. Volar portals in wrist arthroscopy. J Am Soc Surg Hand 2002;2:225-232.}


• The volar aspect of the midcarpal joint can be accessed
through the same skin incision as the volar radial portal.
• A hook probe can be inserted dorsally in the midcarpal
radial portal for palpation.
• The capsular entry site through the volar radial midcarpal
• Wrth tears of the palmar SLIL one can see the intact dor-
portal is entered by angling the trocar 1 em distally and
sal fibers and the volar surface of the capitate.
about 5 degrees ulnarward to the radiocarpal site.


• The volar ulnar portal is established via a 2-<m longitudi- radial direction alone to avoid injury to the ulnar nerve
nal incision centered over the proximal wrist crease along and artery.
the ulnar edge of the finger flexor tendons (IECH RG 3). • The median nerve is protected by the interposed flexor
• The tendons are retracted to the radial side and the ra- tendons.
diocarpal joint space is identified with a 22-gauge needle. • The palmar region of the LTIL can usually be seen slightly
• care is taken to situate the portal underneath the ulnar distal and radial to the portal.
edge of the flexor tendons and to apply retraction in a • A hook probe is inserted through the 6R or 6U portal.

TECH FIG 3 • Technique for volar ulnar portal. A. Skin inci-
sion for volar ulnar portal. KR, flexor carpi radialis tendon;
FDS, flexor digitorum sublimis. B. FDS retracted, saline in-
jection of radiocarpal joint. C. Insertion of cannula through
capsule deep to FDS tendons. (From Slutsky OJ. The use of
a volar ulnar portal in wrist arthroscopy. Arthroscopy
2004;20: 158-163.}



• The volar DRUJ portal is accessed through the volar ulnar • Direct visualization ofthe foveal attachment prevents ac-
skin incision. cidental injury to this structure.
• The joint is entered by angling the 22-gauge needle • The articular disc is seen superiorly.
45 degrees proximally. • Proximal surface tears of the TFCC, which are usually
It is useful to leave a needle or cannula in the ul- caused by severe axial load, may be detected through
nocarpal joint for reference. this portal.
• Alternatively, a probe can be placed in the distal • The dome of the ulnar head lies inferiorly.
DRUJ portal and advanced through the palmar inci- • The TFCC attachment to the sigmoid notch can be pal-
sion to act as a switching stick over which the cannula pated with a hook probe in the distal dorsal DRUJ portal
can be threaded. 3 as it penetrates the dorsal DRUJ capsule.
• Initially, the space appears quite limited, but over the • The deep attachments of the dorsal radioulnar ligament
course of 3 to 5 minutes the fluid irrigation expands the can be seen as it inserts into the fovea.
joint space, which improves visibility. • In ideal cases, the conjoined tendon of the dorsal ra-
• A 3-mm hook probe is inserted through the dorsal distal dioulnar ligament, ulnar collateral ligament. and palmar
DRUJ portal for palpation. radioulnar ligament can be visualized.
• A burr or thermal probe can be substituted as necessary.


• The dorsal aspect of the DRUJ can be accessed through • The distal dorsal DRUJ portal is identified 6 to 8 mm dis-
proximal and distal portals. tally with the 22-gauge needle, and just proximal to the
• The proximal DRUJ portal is located in the axilla of the 6R portal.
joint, just proximal to the sigmoid notch and the flare of • This portal can be used for outflow drainage or for in-
the ulnar metaphysis. strumentation.
• This portal is easier to penetrate and should be used • It lies on top of the ulnar head but underneath the
initially to prevent chondral injury from insertion of TFCC and so is difficult to use in the presence of pos-
the trocar. itive ulnar variance.
• The forearm is held in supination to relax the dorsal • The TFCC has the least tension in neutral rotation of
capsule, to move the ulnar head volarly, and to the forearm, which is the optimal position for visual-
lift the central disc distally from the head of the izing the articular dome of the ulnar head, the under-
ulna. surface of the TFCC. and the proximal radioulnar lig-
• Reducing the traction to 1 to 2 pounds permits bet- ament from its attachment to the sigmoid notch to its
ter views between the ulna and the sigmoid notch insertion into the fovea of the ulna.
by reducing the compressive force caused by axial • Because of the dorsal entry of the arthroscope, the
traction. course of the dorsal radioulnar ligament is not visible
• The joint space is entered by inserting a 22- until its attachment into the fovea is encountered.
gauge needle horizontally at the neck of the distal • Entry into this portal provides views of the proximal
ulna. sigmoid notch cartilage and the articular surface of
Fluoroscopy facilitates needle placement. the neck of the ulna.


• Use shallow skin incisions.
• Use the wound spread technique to protect surrounding sensory nerves.
• If the trocar does not insert easily, reposition to avoid chondral injury.
• Wrist traction often diminishes during the procedure and should be readjusted as needed to avoid scraping the articular surface.
• Use of a standard methodologic approach ensures a complete and thorough examination.

• Active wrist motion is encouraged after this period and pa-

POSTOPERATIVE CARE tients are allowed activities of daily living, followed by grad-
• The postoperative rehabilitation depends on the specifk ual strengthening.
procedure that is performed. • If a ligament repair or TFCC repair has been performed or
• Mter diagnostic arthroscopy, with or without debridement, if there is interosseous pinning, the protocol is adjusted as nec-
the patient is splinted for comfort for a brief period of 4 to essary and typically involves an initial period of immobiliza-
7 days. tion before instituting wrist motion.

• Most of the complications related to use of the dorsal por- 1. Berger RA. Arthroscopic anatomy of the wrist and distal radioulnar
tals are related to injury to the sensory branches of the super- joint. Hand Clin 1999;15:393-413.
2. Geissler WB, Freeland AE., Savoie FH, et al. Intracarpal soft-tissue le-
ficial radial nerve and the dorsal cutaneous branch of the ulnar sions associated with an intra-articular fracture of the distal end of
nerve. the radius. J Bone joint Surg Am 1996;78A:357-365.
The palmar cutaneous branch of the ulnar nerve is at risk 3. Slutsky DJ. Distal radioulnar joint arthroscopy and the volar ulnar
with the volar radial portal, although the interposed flexor portal. Tech Hand Up Extrem Surg 2007;11:38-44.
carpi radialis tendon mitigates this risk. 4. Slutsky Dj. Arthroscopy portals: vo1ar and dOISal. In Budoff j, Slade
There is no true internervous plane when using the volar JF, Trumble TE, eds. Masrer's Techniques in Wrist and Elbow
Arthroscopy. Chicago: American Society furS~ of the Hand, 2006.
ulnar portal; hence, sensory branches of the palmar cuta- 5. Slutsky DJ. Clinical applications of volar portals in wrist arthroscopy.
neous branches of the ulnar nerve or nerve of Henle are Tech Hand Up Extrem Surg 2004;8:229--238.
always at risk. Thus, proper wound spread technique is 6. Slutsky DJ. Management of dorsoradiocarpalligament repairs. J Am
paramount. Soc Surg Hand 2005;5:167-174.
The ulnar neurovascular bundle is also potentially 7. Slutsky DJ. Volar portals in wrist arthroscopy. JAm Soc Surg Hand
at risk with overzealous retraction or poor portal place-
8. Slutsky DJ. Wrist arthroscopy portals. In Slutsky DJ, Nagd DJ, eds.
ment. Techniques in Hand and Wrist Arthroscopy. Philadelphia: Elsevier,
• Venous bleeding, loss of wrist motion (especially forearm 2007.
supination), complications related to fluid extravasation, 9. Slutsky DJ. Wrist arthroscopy through a volar radial portal.
and infection are general risks attendant to any arthroscopic Arthroscopy 2002;18:624-630.
procedure. 10. Steinberg BD, Planclu:r KD, Idler RS. Percutaneous Kirschner wire
fixation through the snuff box: an anatomic study. J Hand Surg Am
These can be minimized by fastidious surgical technique,
aggressive rehabilitation as necessary, and diligent follow- 11. Viegas SF. Midcarpal arthroscopy: anatomy and portals. Hand Clin
up in the early postoperative period. 1994;10:577-587.
I Open Reduction and Intern al
Chapt er 4 I
Fixati on of Diaphyseal
! Forearm Fractures
Michael R. Boland

DEFINITION With rotation, the radius rotates around the ulna, and the
ulna moves in a varus-valgus direction about 9 degrees at
Motion in the human forearm is a complex interaction be-
tween the radius and ulna produced by the combination of
the elbow. This allows the ulnar head to move out of the
way of the rotating radius distally.
multiple muscles working cohereody and hinged at the proxi-
At the distal radioulnar joint (DRUJ), motion between
mal and distal radioulnar joints.
50 degrees pronation and SO degrees supination is almost
• Surgical reconstructio n of diaphyseal forearm .fractures re-
pure rotation, but at the extremes the radius translates in a
quires precise realignment of both radius and ulna to .minimize
dorsal direction during pronation and a palmar direction
complications and maximi.ze function.
during supination.
• Ingenious surgical approaches have been described that
Movement at the proximal radioulnar joint (PRUJ) is pri-
allow the surgeon to follow defined intemervou.s planes to the
marily rotation.
bones for internal .fixation. The design of the forearm allows
• The radius and ulna have two bows that assist in getting out
near 180-degree rotation combining with considerable elbow 22
of the other's way. Schemitsch and Richards quantified the
flexion-extension and wrist circumduction. To achieve this,
importance of the distal of the two bows in the radius.
the ulna is enlarged proximally, making it a principal bone of
Restoration of this bow is the single most important step in
the elbow, and is smaller distally, while the reverse is true for
reconstructio n of the forearm after diaphyseal fracture.
th~ radi~s, with the enlarged radius being the primary articu-
To determine whether the bow has been restored after
latJon With the carpus. The result for the diaphysis of each
osteosynthesis, draw a line from the biceps tuberosity to
bone is that the proximal ulna is metaphyseal for about 25%
the sigmoid notch. A perpendicula r line from the apex can
to 30% of its length but distally less than 10%, with there-
then be measured (FIG 1 ). The normal range of bow is
v~e holding true for the radius. Implant design has taken
15.3 :t 0.3 mm at a point at 60% of the radius measured
these differences into account, with many whole systuns avail-
able for metaphyseal distal radius and proximal ulna fractures.
between the bicipital tuberosity and the distal radius at the
sigmoid notch.
• The importance of maintaining the radial and ulnar heads
At the apex of this bow on the convex aide is the insertion
has only recently been understood. New developments are tak-
of the pronator teres. This provides a biomechanical advan-
ing place, therefore, for the management of distal ulna and
tage for pronation.
proximal radius fractures.
The biceps insertion is at the apex of a smaller proximal
• This chapter discusses ulna fractures distal to the junction of
bow. As a result, the biceps needs to be much larger to
the proximal and middle thirds to the distal margin of the
overcome the disadvantage of insertion into a small bow for
pron.a tor quadratus (PQ) and radius .fractures distal to the bi-
balanced supination.
ceps tuberosity down to the distal t1are of the radius.
The arrangement in the ulna is the converse of the radius:
Pediatric fractures, distal radius and ulna fractures ole-
' a longer shallower proximal bow (the anconeus inserts into
cranon and radial head fra£tures are not covered.
the apex for valgus of the elbow), and a small distal bow for
• Diaphyseal fomum fractures usually are classified accord-
the insertion of the PQ.
ing to the AO classification.
• The radius and ulna are bound together essentially
ANATOM Y throughout their length, with the annular ligament at the
PRUJ, the interosseous ligament through the middle 75%
• The surgical approa£hes to the forearm bones for fracture and the ligaments of the triangular fibrocartilage compl~
ostwsynthesi s involve five steps:
Finding an interval between longitudinally oriented super-
ficial muscles
Finding and preserving vessels and nerves
Understandin g the anatomy of deeper muscles that cross
the forearm obliquely or transversely
Knowing where to lift these muscles to expose the bone
Understandin g the shape of the bones themselves and
their relation to one another
Radius and Ulna
Maximum radial bow a (mm)
• Motion of the forearm involves a complex interaction be-
tween the radius and ulna. LocaUon of maximum radial bow (%) yx 100
The radius rotates around a longitudinal axis that pa88es FIG 1 • !he meth~d of Sche~sch and Richards for quantifying
through the center of the radial head at the proximal radioul- the miiXImum rad1al bow and Its location relative to the length
nar joint and through the center of the ulnar head distally. of the entire radius.1


(TFCC) distally. The TFCC ligaments are the palmar and side of the subcutaneous border of the ulna, sharing a septum
dorsal radioulnar ligaments, which attach to the distal rim of with the FCU.
the sigmoid notch and the fovea of the ulna. Disruption of The ulna is approached along this septum. The anterior
these ligaments often is associated with fractures of the ra- surface and posterior aspects of the ulna can be approached
dius and ulna and may lead to DRUJ incongruity (ie, this way. The true anterior approach to the ulna is along the
Galeazzi. fractures) or radial head dislocation (ie, Monteggia radial edge of the FCU, mobilizing the ulna neurovascular
fractures). bundle and going between the FCU and the flexor cligitorum
profundus (FDP). The FDP occupies the floor of most of the
Muscles and Ligaments
flexor compartment of the forearm.
• The forearm is criss-crossed with longitudinal, oblique, and • Crossing the forearm in itll deepest partll are a series of
transversely directed musculotendinous units. These muscles obliquely oriented muscles. The supinator plays a role in both
are in layers, with longitudinal muscles more superficial and the anterior and posterior approaches to the radius. It has two
crossing muscles deeper. heads of origin and probably can be thought of as two muscles,
• Most activities performed by the forearm, wrist, and hand because the fibers of each head traverse in different directions.
occur from the midpronation position, with the wrist moving The ulnar head attaches to the supinator crest on the ra-
into extension and radial deviation (ERD), then in an arc ac- dial side of the ulna. Its fibers are transverse (like those of
celerating past neutral again, to flexion and ulnar deviation the PQ distally) and attach to the most proximal part of the
(FUD, end of deceleration) before returning to wrist neutral. radius, deep to the posterior interosseous nerve (PIN).
The forearm is designed to ma.ximize the ability to perform The humeral head attaches to the lateral epicondyle, deep
this motion. This wrist motion is commonly known as the to the ECU and anconeus. Its fibers slope down the forearm
"dart thrower's motion" or primary wrist motion. more longitudinally, and wrap over the deep or ulnar head
• The extensor carpi radialis longus (ECRL), the cocking or to attach to the radius distal to the ulnar head of the supina-
lifting muscle of primary wrist motion, originates proximal to tor and proximal to the insertion of the pronator teres.
the lateral epicondyle on the supracondylar ridge, is positioned In an anterior approach to the radius, the forearm is
"above" the forearm, and inserts into the radial and dorsal as- supinated, protecting the PrN, and the humeral head of the
pect of the index metacarpal. supinator is lifted from ita most ulnar attachment.
• On either side of the ECRL is the brachioradialis (BR), • The pronator teres originates mainly from the medial supra-
which originates high on the lateral supracondylar ridge, in- condylar ridge, arches obliquely across the ulnar artery and me-
serting on the radial styloid deep to the .6rst dorsal compart- dian nerve, and inserts into the apex of the larger bow of the
ment, and the extensor carpi radialis brevis (ECRB), which radius. Proximally, it is superficial, but distally, where it must
originates more distally just above the lateral epicondyle and be lifted from the radius, it is deep to the BR muscle (FIG 2). It
inserts into the long finger metacarpal. ECRL and ECRB share must be lifted from the most radial aspect of the radius in the
the second dorsal compartment at the wrist. anterior approach.
• Together the BR, ECRL, and ECRB form a mobile wad • Distally in the floor of the anterior compartment the PQ
above the forearm (in the functional position). They are inner- muscle comes into play in anterior approaches to the radius
vated directly by the radial nerve and are best palpated just and ulna. It must be lifted from the radial border in an ap-
distal to the elbow. proach to the radius and the ulna border in an approach to
In a posterior approach to the radius, which is per- the ulna.
formed in pronation, after incising the deep fascia, the • In a posterior approach to the radius, the abductor pollicis
dissection interval is between the ECRB and the extensor longus muscle drapes across the radius just distal to ita mid-
digitorum communis (EDC) muscle. The EDC originates point. It can be lifted to allow plate fixation to this part of the
from the lateral epicondyle (where it shares a common ori- radius. Its ulnar origin is always left intact.
gin with the extensor digiti minimi) and passes essentially
in a straight line down the forearm, then through the
fourth dorsal compartment at the wrist, just ulnar to
Lister's tubercle.
In an anterior approach, which is performed in supina-
tion, the deep fascia is incised along the medial border of the
BR. The BR is then mobilized radially and the interval be-
tween it and flexor carpi radialis is developed. The FCR, like
the EDC, has a straight course in the forearm from the me-
dial epicondyle to the scaphoid tubercle (where it passes en
route to the index metacarpal).
• The muscle of utmost importance in approaches to the ulna
is the flexor carpi ulnaris (FCU). It is the primary accelerator
of the wrist, and thus has a large tendon (equal to the me-
chanical strength of the ECRL and ECRB combined), which
originates from two heads, one from the medial epicondyle
and one from the ulna. It proceeds straight down the forearm FIG z • Anterior approach. The interval between the brachiora-
along the ulna border and inserts into the pisiform. From the dialis and flexor carpi radialis is entered, and the radial artery is
distal tip of the lateral epicondyle originates the extensor retracted laterally. The supinator, pronator teres, flexor pollicis
carpi ulnaris, which runs down the forearm on the extensor longus, and flexor digitorum superficialis can be seen.

Nerves • An isolated radius fracture often is associated with a fall

• The forearm is traversed longitudinally with three major onto an outstretched hand.
nerves plus an additional three sensory nerves, only one of
which is of surgical importance. Once the interval between NATURAL HISTORY
muscles is breached, care is taken to find these nerves. Each • Normal function of the human forearm requires the radius
nerve enters the forearm from the arm in a predictable place, to rotate around the ulna.
and each gives off key branches that must be protected. • Matthews 15 showed in a cadaveric study that 10 degrees of
• Although the radial nerve supplies all the extensor muscles of angulation of one or both bones of the forearm results in a loss
the arm and forearm, it is an anterior structure after it pierces of 20 degrees of pronation and supination. Thus, the natural
the lateral intermuscular septum 10 em above the elbow. history is highly dependent on the position of healing of the
At the dbow the radial nerve lies between the BR and the two forearm bones.
brachialis and gives off the PIN. • It is reasonable to consider nonoperative treatment of an
The radial sensory nerve continues deep to the BR muscle, isolated ulna fracture with less than 10 degrees angulation,21
on its undersurface. Here, the nerve generally lies close to but nonoperative treatment of both-bone forearm fractures
the radial artery. The anterior approach to the radius is has a poor outcome. 8 •13
through the interval between the nerve and artery.
The posterior interosseous branch leaves the main nerve PATIENT HISTORY AND PHYSICAL
just distal to the dbow and passes through the supinator FINDINGS
muscle, between its two heads, to enter the dorsal or exten- • In most cases, the initial presentation of a radius or ulna di-
sor compartment of the forearm. aphyseal fracture makes the diagnosis obvious. Most fractures
As it leaves the supinator, it fans into multiple variable are displaced due to the high-energy nature of the traumatic
branches to supply the EDC, EDM, and ECU, with the event and, therefore, deformity is common. Patients with
majority of the nerve continuing distally deep to the inter- nondisplaced fractures usually have considerable pain and
val between EDC and ECRB. swdling in the forearm.
• The course of the ulnar nerve is represented by a line drawn Despite the ease of initial diagnosis, the treating physician
from the medial epicondyle to the pisiform. Throughout the must be on guard for significant associated injuries and
forearm the nerve is deep to the FCU muscle and lies deep and complications, not only of the bone and joint but also of
slightly radial to the tendon of this muscle at the wrist. soft tissue.
Throughout most of the forearm the nerve is between the FCU • A systems approach to these associated injuries is as follows:
and the FDP. Skin: Look at the skin for any evidence of laceration or
• The median nerve enters the forearm between the brachial abrasion. A laceration may communicate with the fracture
artery and the tendon of the biceps brachii. It lies deep to the site; therefore, a contaminated abrasion at the site of surgi-
pronator teres, then passes deep to the fibrous arch of the FDS. cal incision should be allowed to heal before surgery.
The nerve is closely associated with the undersurface of the Fascia: Tense tissues to palpation over the flexor or exten-
FDS as it travels distally. sor compartments and pain with passive finger extension are
Blood Supply evidence of compartment syndrome, and compartment
release must be considered.
• The vascular anatomy is of critical importance in the flexor Vascular: Radial and ulnar pulses distal to the site of in-
compartment. jury must be palpated and compared to the uninjured side.
The brachial artery enters the forearm deep to the lacer- These pulses can be difficult to palpate due to the proximity
tus fibrosus, next to the median nerve. It almost immedi- of the fractures, so checking capillary refill in the digits is the
atdy branches into radial and ulnar arteries. next step. In the multiply injured patient, the peripheries are
The ulnar artery passes deep to the arch of origin of the shut down, making capillary refill and pulses difficult to
FDS to lie next to the ulnar nerve throughout the distal two perform. In such a situation, a needle stick to the digit
thirds of the forearm. should reveal bright red blood.
The radial artery is pushed more superficial by the bulk of Nerve: Assessment of nerve injury is summarized later in
the FDS and the pronator teres lying just deep to the fascia this chapter.
along the medial border of the BR muscle. Bone: The joints above and below the fracture must be
palpated for associated joint disruption.
PATHOGENESIS • For any upper extremity injury, a history of the causative
• The degree of injury and specifics of the fracture are directly event is essential to understand the degree of energy that the
related to the magnitude, direction, and duration of energy. limb has had to absorb. Given the common association with
Both-bone forearm fractures are common in motor vehi- high energy, the patient must be assessed according to an ap-
cle trauma. propriate trauma checklist protocol.
Industrial trauma often is associated with a high level of • The patient must be questioned specifically regarding elbow
soft tissue injury. or wrist pain, and neurologic symptoms of numbness, tingling,
Forearm fractures occur relatively commonly in some or unusual sensation in the hand. Severe pain should suggest
sports, eg, rugby in all its forms and wrestling. the possibility of compartment syndrome or vascular injury.
• The most common mechanism of injury is a direct blow to • Palpation of the mid-forearm should be gentle, step by step
the mid-forearm. If this blow is directed primarily at the ulna, feding along the radius and ulna. A tense forearm may indi-
an isolated ulna shaft fracture results ("nightstick" fracture). cate a compartment syndrome.

• Palpation should then pro~d over the DRUJ and ulnar • On a lateral radiograph of the elbow, the radial head
head plus PRUJ and radial head. Palpation should be per- should align dire~tly with the ~apitellum of the distal
formed of the medial and lateral epk:ondyles, of the s~aphoid humerus. Monteggia17 in 1814 des~ibed a fra~ture of the
in the snuff box, and over ~arpal bones and the car- proximal third of the ulna with an anterior radial head dislo-
pometa~arpal joints. ~ation, and Bado2 later subclassified these a~~ording to dire~­
A systematic examination of the median, ulnar, and radial tion (FIG 3).
nerves involves examination of sensory and motor aspe~ts
The sensory examination involves stati~ two-point dis- • Pathologi~ fra~e may result from a number of ~auses.
~imination of the digital nerves and light toud over the Metabolic causes: osteoporosis, estrogen deficien~y,
autogenous zones of ea~h nerve. renal transplantation, vitamin D deficien~, parathyroid
Motor examination is graded by Mediw Researd disease, Cushing disease, hyperthyroidism, hypogonadism,
Council (MRC) grading and is done by stressing the ap- hypophosphatasia
propriate joint and palpating the aff~ted mu~le. Primary tumors: osteosarcoma, Ewing sarcoma and prim-
itive neuro~todermal tumors, dondrosar~oma, myeloma,
IMAGING AND OTHER DIAGNOSTIC fibrous histio~ytoma, desmoplasti~ fibroma, hemangioma,
STUDIES intraosseous lipoma, a~ute myeloid leukemia, Langerhans'
• High-quality plain radiographs of the forearm, wrist, and ~ell histio~ytosis, fibrous dysplasia, dondroblastoma
elbow are the mainstay of diagnosis of diaphyseal radius and Metastatic tumors: breast, thyroid, lung, prostate,
ulna fra~tures. melanoma
• Mino 16 des~ribed a tednique to interpret the lateral wrist Infection: osteomyelitis, tuberculosis
radiograph whereby the radial styloid is aligned with the Congenital disorders: Turner syndrome, neurofibromato-
center of the lunate, and an assessment of the overlap of the sis pseudoarthrosis, osteogenesis imperfe~ta
radius and ulna is made. The head of the ulna should be ~om­ • Iatrogenic fracture: post-plate/s~rew removal; post-
pletely obs~ured by the radius. If only part of the ulnar head is osteo~utaneous radial forearm flap; post-elbow, forearm, and
ob~ured by the radius, then there is subluxation of the head; wrist manipulation
if the ulnar head is clearly seen, there is dislo~ation. Any shift • Stress fra~ture
in the ulnar head is a subluxation and, when ~ombined with a
radius fracture, represents a Galeazzi fra~ture-dislocation.9 NONOPERATIVE MANAGEMENT
• A CT s~ in neutral, pronation, and supination is useful in • Slight deviations in the spatial orientation of the radius and
interpreting the degree of DRUJ ~ongruity. This is rarely used ulna will signifi~tly d~ease the forearm's ability to rotate,
in the a~ute setting. impairing hand fun~tion.

Table 1 Methods for Neurologic Examination After Radius and Ulna Fracture

Examination Technique Grading Significance

Median nerve autogenous zone Ught palpation over the palmar Compare sides: can be considered If altered or absent consider median
aspect of the index MP joint crease normal, absent or altered. nerve palsy. Examine median
distribution two-point discrimination.
Ulnar nerve autogenous zone Ught palpation over the palmar Compare sides: can be considered If altered or absent consider ulnar
aspect of the small finger MP joint normal, absent, or altered. nerve palsy. Examine ulnar distribution
crease two-point discrimination.
Radial nerve autogenous zone Ught palpation over dorsal first Compare sides: can be considered If absent consider radial nerve palsy.
interosseous space normal, absent, or altered.
First dorsal interosseous Abduction of first dorsal MRC muscle grading If weak, consider ulnar nerve lesion.
muscle !Est interosseous against resistance
Abductor pollicis brevis Abduction of thumb against MRC grading If weak, consider median nerve lesion.
muscle test resistance with palpation of
thenar space
Extensor pollicis longus Extend the interphalangeal joint MRC grading If weak, consider radial nerve palsy.
muscle test of the thumb against resistance
and hyperadduct thumb while
palpating the extensor pollicis
longus tendon.
Flexor pollicis longus Flex interphalangeal joint of thumb MRC grading If weak, consider palsy to anterior
muscle test against resistance. interosseous branch of median nerve.
Passive stretch test Passively extend all fingers. Severe pain may indicate Consider intracompartmental pressure
compartment syndrome. monitoring.

MRC Medical Researdl Council system.

39 -

Where there is equal comminution or no comminution,

the radius is generally approached first.
Should fixation be completed on one bone before ap-
proaching the other?
I recommend not completing fixation but stabilizing
one bone before proceeding to the next. This allows re·
duction of the second bone.
In a stable, non-comminuted fracture, "'temporary
stability" may mean a plate and one screw through
two cortices on each side of the fracture. In a comminuted
fracture, it may mean four cortices and two screws on
IV each side.
Completion of fixation should occur after the second
bone is reduced and stabilized.
What implant and what length of implant should be used?
The plate must span the fracture complex and provide
six cortices of fixation in stable bone, both proximally
and distally.
Non-<:omminuted transverse fractures require at least a
six-hole small fragment limited contact-dynamic com-
FIG 3 • The Bado classification of Monteggia lesions lists four pression (LC-DC) or locking plate.
types, depending on the direction of the radial head. In type I Oblique fractures and comminuted fractures require a
lesions the head is anterior to the distal humerus. In type II le- longer plate. Oblique fractures are treated with an inter·
sions it is posterior. and in type Ill lesions it is lateral. Type IV fragmentary screw or screws at right angles to the fracture
fracture-dislocations involve a dislocation of the radial head as- line and a seven-hole plate.
sociated with a fracture of both the radius and the ulna. A unicorticallocked screw can be considered "'bicorti-
cal," but practically speaking, this rule is used only for the
screw hole furthest from the fracture. In almost all situa·
• Fractures of the radius and ulna can be regarded as articu- tions there must be three screw holes in the plate over sta·
lar fractures in the sense that functional restoration requires ble bone away from the fracture complex.
anatomic reduction. In distal metaphyseal, diaphyseal fractures of the ulna,
• The only indication for nonoperative treatment is a nondis- it often is impossible to get six cortices of fixation. In this
placed fracture of the ulna,14•21 or if the patient's general con- situation, two mini fragment plates (with 2.7-mm screws)
dition makes operative treatment ill advised. applied at a 90-degree angle to each other provides excel·
In the case of a displaced fracture, closed reduction and lent fixation.
cast immobilization sometimes is possible but is unreliable. • Anterior and posterior approaches can be used to treat frac-
Loss of initial satisfactory reduction is common.3•&,t2,ll
tures along the entire length of each bone. The anterior ap-
• The treatment of choice for adult diaphyseal forearm frac- proach to the radius is preferred when possible.
tures is open reduction and internal fixation. 1•7•20
This location allows for excellent soft tissue coverage, re·
ducing the need for plate removal.
SURGICAL MANAGEMENT • Most diaphyseal forearm fractures are best stabilized by
• The most couunon scenario is fractures of the radius and plates and screws, but other implants sometimes are indicated.
ulna in the middle third of both bones. The most couunon • External fixation may be used in the following settings:
questions confronting the surgeon are considered here. Open fractures with severe soft tissue damage, as a tempo·
Which approach should be used? rizing measure until reconstruction can safely be undertaken
The anterior surface of the radius and ulna is the best Maintenance of length in fractures with severe bone loss
location for a plate. This surface is broad and flat on both (this usually occurs in open fractures)
bones, and a plate on this surface is covered with muscle, Patients with multiple injuries ("damage control"
resulting in less plate irritation for the patient. surgery)
Consequently, I prefer the anterior approach to both The ttizarov technique is useful in segmental fractures, es·
the radius and the ulna. In addition, the patient is posi- pecially when the fractures are very dose to the wrist and
tioned supine for these approaches, reducing the need to elbow joints.
reposition the patient during the procedure. • Intermedullary nailing is used in the following settings:
Should one or two incisions be used? Young women who desire a better cosmetic result
Use of two incisions markedly decreases the risk of syn- Segmental fractures
ostosis, decreases the length of the incision, and reduces Re-fracture at the bone plate interface in a contact athlete
tension on the skin and soft tissue by retractors. or following plate removal
Which bone should be stabilized first?
The fracture with the least comminution should be ap- Preoperative Planniug
proached first and stabilized. This allows for length to be • The surgeon must develop a strategy to achieve satisfactory
restored in the forearm, allowing easier judgment of alignment of the radius and ulna with congruency of the PRUJ
length in the more comminuted bone. andDRUJ.

• Factors that must be considered include the following: her chest and secured with broad paper tape to the operating
Operating room time and availability (ideally within 7 days table. A hand table is used to rest the instruments rather than
of the injury) support the upper extremity. If other forearm fractures are
Implant and equipment availability (eg, a distraction present, however, the arm table may then be available.
device) • A non-sterile tourniquet is applied to the upper arm before
Patient factors and patient support factors (in outpatient prepping and draping the patient.
surgery a supportive family or friend is needed in the early • The surgeon usually is seated on the side of the hand table
postoperative period) closest to the bone being reduced and stabilized.
Regional versus general anesthesia • For the anterior approach to the radius, the surgeon is on
• Standard AO planning18 consists of drawing the fragments the side of the table closest to the patient's head. The forearm
on transparent paper; superimposing the transparent sheets to is supinated and the elbow extended. For a posterior ap-
align the bones; adding a chosen implant template; and draw- proach to the radius, the forearm is pronated and the elbow
ing the final outcome corresponding to the expected postoper- extended.
ative radiograph. With experience in fracture management, • For a posterior or subcutaneous approach to the ulna, the
these steps are intuitive. elbow is flexed, and the forearm is in a neutral position.
• AO principles of internal fixation using plates and screws
should be reviewed by the surgeon before attempting internal Approach
fixation. • The anterior approach to the radius is the standard ap-
proach for a radius fracture, but the posterior approach is use-
Positioning ful when soft tissue lesions are posterior or the anterior ap-
• Generally, the patient is positioned supine and the hand proach is compromised in some way.
table is attached to the main table so the midpoint of the hand • The posterior or subcutaneous approach to the ulna is the
table is direcdy opposite the patient's shoulder. The shoulder common approach. I prefer an anterior approach, however,
is directly over the adjoining point of the hand and main because the anterior border of the ulna is flat. and, therefore,
tables. The arm is abducted to 90 degrees at the shoulder, so the plate fits better and is buried deep to the FCU and FDP
the entire arm lies across the midpoint of the hand table. muscles, reducing plate irritation.
• In the case of a posterior approach to the proximal ulna, the • In general, the incision is 2 em longer than the implant to be
patient is positioned supine and a pillow is placed across his or utilized.


• The anterior approach to the radius, first described by • The skin is incised, and the superficial tissues are carefully
Henry,17 is one of the classic approaches in orthopaedic dissected, looking for the lateral antebrachial cutaneous
surgery. nerve Oateral cutaneous nerve of the forearm) (IEat
• A straight metallic instrument is placed on the forearm FIG 1D).
skin, and a C-arm image is taken to judge the position of
the fracture. The skin is marked (.'IEat FIG 1A).
• At the level of the deep fascia, a Rayte<:h (Rayte<:h
Industries, Middletown, CT) is used to sweep the soft tis-
• The biceps tendon and radial styloid are found and sues so that the ulnar edge of the BR can be seen (IEat
marked. The diathermy cord is extended between these FIG 1E).
points (.'IECH FIG 1B), and the skin incision is marked
centered on the fracture site (IEat FIG 1C).
• The deep fascia is incised along the ulnar edge of the BR,
and the BR is mobilized and lifted (.'IECH FIG 1F). Thera-
dial nerve and radial artery are found deep to the BR.
• The interval between the radial artery and nerve is
opened (IEat FIG 1G,H}, exposing the radius.
• The radial aspect of the pronator teres insertion is dis-
sected off the radial shaft. in this case exposing the dis-
tal fragment (IEat FIG 11).
• For more proximal exposure, follow the radial sensory
nerve proximally to the place where it and the poste-
rior interosseous nerve bifurcate (IEat FIG 1J).
A • The supinator is dissected off the ulnar aspect of the
radius to protect the PIN, thus exposing the proximal
1Eat FIG 1 • Anterior approach to the radius. A. The patient
is positioned supine, with the forearm supinated. In this fragment (.'IEat FIG 11Q.
image the elbow is to the left and the wrist to the right. A • The fracture is then reduced and held following AO pri~
straight metal instrument is placed across the forearm, and a ciples. I prefer six cortices of screw fixation on either side
C-arm fluoroscopic image is taken to confirm the level of the of the fracture and currently use the Synthes Small
fracture. (continued) Fragment Locking Compression Plates as fiXation.

1Eat FIG 1 • (continued) B. The estimated level of the fracture is marked. The ra-
dial styloid and biceps tuberosity are marked, and the diathermy cord is placed
between these two points to align the incision. C. The incision is centered on the
fracture. The length of the incision depends on fracture comminution. the primary
determinant of implant length. The most common implant used is a seven-hole 3.5-
mm small fragment plate, and the incision is 2 em longer than the implant. D. The
incision is made and the lateral cutaneous nerve of the forearm is isolated in the su-
perficial fat and preserved. E. The incision is continued to the deep fascia, and the
fascia is swept with a Raytech sponge (Raytech Industries, Middletown, CT). The fas-
cia is incised at the ulnar edge of the brachioradialis. F. The brachioradialis muscle
and tendon are mobilized. G. The radial artery and radial nerve are located, and the
dissection is continued through the fascia between these structures. H. The radius is
exposed over the length of the incision. 1. The pronator teres insertion is dissected
off the radial shaft from the radial aspect of the bone, in this case exposing the dis-
tal fragment. J. In this image, the elbow is at the top. For proximal exposure of the
radius, the superficial radial nerve is traced proximally to the posterior interosseous
branch. K. The elbow is to the right in this image. The supinator is dissected from the
ulnar aspect of the radius to protect the posterior interosseous branch of the radial
nerve, exposing the proximal fracture fragment.


• The posterior approach to the radius also is known as the • The ECRB is part of the mobile wad of Henry,10 which
dorsolateral approach or Thompson's approach.24 also includes the BRand the ECRL. This usually can be
• Lister's tubercle is palpated at the dorsal aspect of the palpated and can help guide placement of the skin
distal radius and marked. The lateral epicondyle of the incision.
humerus is palpated and marked. • After the skin incision and superficial dissection are per-
• The diathermy cord is extended between these bony formed, the interval between the ECRB and EDC is
prominences, and the skin incision is centered on the opened distally where the abductor pollicis longus tranr
fracture site. versely spans the forearm (IECH RG 2B).
• A straight metal instrument is placed transverse to • Extending the interval proximally reveals the PIN as it
the forearm, and fluoroscopy is used to find the level leaves the supinator. Here, it is always accompanied by a
of the fracture site, which is marked with a transverse leash of vessels, the posterior interosseous artery, and its
line. venae communicantes.
• The approach uses the theoretical internervous plane be- • The surgeon must be cautious at this stage, because
tween the ECRB (radial nerve) and the extensor digito- as it leaves the supinator, the PIN quickly gives off
rum (PIN; 1Eat FIG 2A). small branches to the EDCand ECU. The main nerve at

Extensor carpi
longus Abduc!Dr pollicis

A Extensor digitorum B

Posterior interosseous Abductor polllcls Posterior inhuru;li:A;~w;

c nerve longus D nerve (preserved)

1Eat FIG 2 • Posterior approach to the radius. A. After incising the deep fascia, the interval between the extensor carpi
radialis brevis and the extensor digitorum communis muscles is identified. B. The interval between the extensor carpi ra-
dialis brevis and extensor digitorum is developed. C. Further dissection of the interval proximally with splitting of the
aponeurotic origin of the extensors reveals the supinator and the posterior interosseous nerve as it leaves the arcade of
Frohse. D. Development of the interval between extensor carpi radialis brevis and extensor pollicis longus reveals the ra-
dius distal to the extensor polli<is brevis. Proximally, the nerve can be mobilized where it exits the supinator if required.
The posterior interosseous nerve should be identified and protected throughout the whole procedure.
this stage can become relatively small, taking on the into the field over the middle radius, and distally
appearance of a branch. the abductor pollicis longus must be carefully lifted
• Branches to the long muscles to the thumb also can from the radius to provide room for the plate ClEat
come off relatively high, giving a fan-like appearance FIG 2D).
to the nerves and branches ClEat FIG 2C). • The fracture is then reduced and held with a plate and
• The PIN must be mobilized from the deep head of screws. 1 prefer a locked small fragment plate (Synthes)
supinator. The deep head is then split to reach the ra- with six cortices on either side of the fracture.
dius proximally. Fibers of the pronator teres encroach • The deep fascia is closed, followed by the skin.


• The anterior approach is my preferred approach for fixa- metal instrument can be placed on the patient trans-
tion of the distal two thirds of the ulna, because the verse to the long axis of the forearm, and a C-arm
plate is buried deep to the FCU and FDP muscles and the image taken to confirm that the incision is centered
anterior surface of the ulna is flat, much Iike the anterior on the fracture site (IEat FIG 3A).
surface of the radius. This allows for minimal contouring • The skin incision should be through skin and dermis only.
of the plate and minimal overhang of the plate over the • If the fracture is relatively distal, care should be taken to
borders of the bone. avoid injuring the dorsal branch of the ulnar nerve,
• The bony landmarks for the incision are the medial epi- which exits between the FCU and the ulna about 4 em
condyle of the humerus and the ulnar aspect of the pisi- proximal to the ulnar head.
form at the wrist. • The dissection continues directly deep down to the fascia
• As with the radius approach, the diathermy cord can overlying the FCU muscle. The epimysium and fascia are
be extended between these two points, a straight incised in the line of the incision ClEat FIG 31), and the

1Eat FIG 3 • Anterior approach to the ulna. A. The radial incision has been temporarily closed with
staples. The medial epicondyle and ulnar aspect of the pisiform are marked. Using a similar technique
to that described in Tech Fig 1A. with C...:srm fluoroscopy and diathermy lead, the incision is centered
on the fracture. B. The deep fascia and epimysium of the flexor carpi ulnaris are opened. The fascia is
mobilized off the FCU and followed around the ulnar border of the muscle. c. The interval between
the flexor carpi ulnaris and extensor carpi ulnaris is incised, and the ulna exposed subperiosteally at
the level of the fracture site. A Hohmann retractor lifts the FCU. D. The flexor digitorum profundus
and distally the pronator quadratus are lifted, the fracture is reduced, and a locked small fragment
plate applied. (The elbow is to the left and the wrist to the right.}

dissection continues superficial to the FCU muscle ulnarly • I prefer to use six cortices of fixation on either side of the
around onto the ulna ('IECH FIG 3C}. fracture, but this is not possible within 3 em of the ulnar
• Dissection is continued proximally and distally in the i~ head. In this situation, two 2.7-mm mini-fragment plates
terval between the FCU and ECU, and the fracture is r~ are placed at right angles to each other.
duced and held with a locked small fragment plate • The fascia and epimysium are closed together, and skin
(Synthes; 1ECH FIG 3D). closure follows.


1 The posterior approach is preferred for fractures of the entire subcutaneous border of the ulna can be palpated.
proximal third of the ulna diaphysis but can be used to The incision is centered on the fracture, over the subcuta-
expose the entire ulna. neous border or in line with the olecranon and ulnar head.
• Distally, the dorsal branch of the ulna nerve is at risk • The incision is deepened down to the fascia, and in
where it exits between the FCU and the ulna, but it usu- most cases the epimysium over the ECU is opened. The
ally passes distal to the head of the ulna where it crosses ulna is exposed in the interval between the ECU and
the ECU tendon sheath and the extensor retinaculum. FCU distally and between the FCU and anconeus
1 The interval for the approach is between the ECU and proximally.
FCU, which share a short fascial septum along most of • The fracture is reduced and held following AO
the length ofthe ulna. principles with a locked small fragment plate. The
1 The olecranon and ulnar head can be palpated on all pa- plate usually is placed on the lateral surface of the
tients, and marked. In slim individuals, the fracture and the ulna.


I Once the bone is reached by an anterior or posterior ap- • The clamp is then lifted and the plate slid beneath and
proach, reduction and fixation are performed. the clamp replaced (IECH RG 4E).
1 Bon~holding clamps allow delivery of the fracture ends • In its mid-portion the radius is bowed, but the plate is
into the wound ('IECH FIG 4A,}. straight. The plate will always appear to sit obliquely
• For an oblique fracture, a lobster claw bone reduction even when properly applied.
clamp is placed on either side of the fracture site and • The two screw holes closest to the fracture are filled first,
angled about 30 degrees to the longitudinal axis of the followed by placement of an interfragmentary screw
bone. This allows control of both fracture fragments. (IECH RG 4F).
1 The fracture fragments are completely cleaned of all soft • In both-bone fractures, the second bone is now ap-
tissue debris (IECH RG 48). proached and stabilized in a similar manner before final
1 The fracture fragments are reduced using longitudinal fixation of the first fracture.
traction and rotation (IECH FIG 4(). • Locking (IECH RG 4G) or no~locking screws are placed
1 Once this is accomplished provisional stability is obtained in the remaining open screw holes, and fixation is com-
using a bone clamp a<l'OSIS the fracture site (TECH RG 4D). plete ('IECH FIG 4 H).

TECH RG 4 • Reduction of an oblique fracture. A. A lobster-claw bone reduction clamp is placed on
either side of the fracture site and angled about 30 degrees to the longitudinal axis of the bone. Each
end of the fracture is delivered into the wound. B. The fracture fragments are completely cleaned of
all soft tissue debris. (continued)

c D


1Eat FIG 4 • (com.inued) C. Fracture reduction is obtained using longitudinal u-action. and rotation ap-
plied through the lobster clamps. D. The lobster-claw bone clamp temporarily secures the fracture site.
E. The damp is lifted and the plate slid beneath. F. One screw on each side of the fracture and closest
to the fracture is placed first. followed by an interfragmentary screw. G. Locking guides attached to the
proximal two holes allow placement of the locking screws in this Synthes plate. H. Fixation is complete.


Plate irritation on the subcutaneous • Use an anterior approach on the distal half to two thirds of the diaphysis and place
border of the ulna the plate on the anterior (volar} surface. Be very diligent about screw length, because
long screws can be felt dorsally. Place the plate more proximally on the lateral surface.
Proximal exposure ofthe radius • When in doubt, find the nerve. This is mandatory in a posterior approach, but in an
and the posterior interosseous nerve anterior approach follow the superficial radial nerve to its bifurcation proximally.
The wound is tight and difficult • Leave the wound open, admit the patient to the hospital for strict elevation, and revisit
to close. the operating room in 48 to 72 hours. The wound usually will have closed at that time.
This scenario is far more predictable and easier to deal with than a compartment problem
and a wound slough.
Should the fascia be closed? • In most patients, the fascia can be safely closed, but when it is tense, leave open and
consider the above.
Distal radioulnar joint and forearm • Always examine the DRUJ for stability at the end of the case, and put the forearm dtrough
rotation a range of motion. Then obtain radiographs of the wrist.
• DRUJ instability can be subtle and may not be picked up until late.
• DRUJ problems can occur in the presence of an ulna fracture.
• If the forearm is not able to complete a full ROM (compare opposite forearm}, that usually
means the radial bow has not been preserved.
Proximal radioulnar joint • As with the DRUJ an elbow AP and lateral should be performed at the end of the case.

POSTOPERATIVE CARE • With attention to detail, using the appropriate anatomi~ ap-
proad, accurate redu~tion, and the use of hardware that pro-
• The key points in inunediate postoperative ~are are splint-
vides adequate bone stability, out~omes from diaphyseal fra~­
ing, pain relief, elevation of the extremity, and watching for
tures of the forearm are as good as any in orthopaedi~ surgery.
signs of ~omplkations.
The patient usually rereives axillary blod anesthesia,
which allows him or her to return home pain-free. REFERENCES
A sugartong splint is pla~ed at the time of surgery and is 1. Anderson ID, Sisk D, Tooms RE, et al. Compression-plate fixation
in acute diaphyseal fractures of the radius and ulna. J Bone Joint Surg
worn for 2 weeks, at which time the patient returns to the
Am 1975;57:287.
offi~e for a removal of splint and sutures.
2. Bado JL. The Monteggia lesion. Orthop Relat Res 1967;
Nar~oti~ pain relief usually is ~eased at 2 weeks. 50:71-86.
Radiographs of the wrist, elbow, and forearm are ordered 3. Bolton H, Quinlan AG. The conservative treatment of fractures of the
at the 2-week visit. shaft of the radius and the u1na in adults. Lancet 1952;1:700.
• At the 2-week visit the patient is referred for physkal ther- 4. Botting ID. Posttraumatic radio-ulna cross union. J Trauma 1970;
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• From 2 to 6 weeks, the patient is given a 5-pound weight 6. Brostrom LA, Stark A, Svartengrcn G. Acute compartment syndrome
lifting restriction and is pla~ed on restricted work duty, includ- in forearm fractures. Acta Orthop Scand 1990;61:50-53.
ing no repetitive forearm twisting, until union o~~urs. 7. Chapman MW, Gordon JE, Zissimos AG. Compression-plate :6..xa-
• At 6 weeks, simple two-part fractures usually are united and tion of acute fractures of the diaphyses of the radius and ulna. J Bone
all lifting and twisting restrktions are removed. If there is no Joint Surg Am 1989;71A:159-169.
8. Evans EM. Rotational deformities in the treatment of fractures of
eviden~e of union, the patient is placed on a 20-pound weight
both bones of the forearm. J Bone Joint Surg Am 1945;27A:373-379.
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der Unteraumknochen. An:h OrthoUnfallchir 1934;35:557-562.
OUTCOMES 10. Henry AK. Extensik Exposure, 2nd ed. Baltimore: Williams &
Wilkins, 1970.
• In two-part fra~ture of the radius and ulna, patients ~an ex- 11. Hertel R, Pi.san M, Lambert S, et al Plate osteosynthesis of diaphy-
pe~t over 95% problem-free ~onsolidation before 6 months. In seal fractures of the radius and ulna. Injury 1996;27:545-548.
a study by Hertel, 11 out of 132 patients there were two de- 12. Hughston JC. Fracture of the distal radial shaft: Mistakes in manage-
layed unions and two non-unions that required reoperation. ment. J Bone Joint Surg Am 1957;39:249-264.
Plates were removed from 70 patients (53%) at a mean of 33.1 13. Knight RA, Purvis GD. Fractures of both bones of the forearm in
adults. J Bone Joint Surg Am 1949;31A:755-764.
months (range 8-122 months) after the first operation. In this 14. Mackay D, Wood L, Rangan A. The treatment of isolated u1nar frac-
group, there were three refra~tures (4.3%) o~urring at a mean tures in adults: a systematic review. Injury 2000;31:565-570.
of 8.7 months (range 0-14) after plate removal. In another 15. Matthews LS, Kaufer H, Garver DF, et al. The effect on supination-
study by Chapman/ 98% of the fra~tures united, and 92% of pronation of angular malalignment of fractures of both bones of the
the patients achieved an ex~ellent or satisfa~tory fun~tional forearm. J Bone Joint Surg Am 1982;64A:14-17.
result. 16. Mino DE, Palmar AK, Levinsohn EM. The role of radiography and
computerized tomography in the diagnosis of subluxation and dislo-
• Nonunion rates are mud higher in oomminuted fra~tures,
cation of the distal radioulnar joint. J Hand Surg Am 1983;8:23-31.
approximately 12%, but it has been shown that bone grafting 17. Monteggia GB. lnstituzioni Chirurgiche Vol. 5. Milano: Maspero,
primarily does not lead to improved outoomes. 19 1814.
18. Muller ME, Allgower M, Schneider R, et a!. Manual of Internal
COMPLICATIONS Fixation: Techniques Recommended by the AO-ASIF Group. New
York: Springer-Verlag, 1991.
• Complkations of forearm fra~tures include ~ompartment 19. Ring D, Rhim R, Carpenter C, et al. Comminuted diaphyseal frac-
syndrome,6 malunion,25 nonunion,S and radioulnar synosto- tures of the radius and ulna: Does bone grafting affect nonunion rate?
sis.4 The rate of infe~tion is about 2%. 7 J Trauma 2005;59:438-441.
• In a study by Stem23 of 64 adult patients with 87 diaphyseal 20. Rosacker JA, Kopta JA. Both bone fractures of the forearm: A review
of swgical variables associated with union. Orthopaedics 1981;
forearm fra~tures treated by plating, 18 patients (28%) had a
major oompli~ation. There was a nonunion rate four times 21. Sarmiento A, Latta U., Zych G, et a!. Isolated ulnar shaft fractures
higher for bones plated with four screws than six screws, and treated with functional braces. J Orthop Trauma 1998;12:420-423.
screws loosened in three fra~tures, all involving the ulna. 22. Schemitsch EH, Richards RR. Tlu: effect of malunion on functional
Radioulnar synostosis o~urred in seven forearms, and in five outcome after plate fixation of fractures of both bones of the forearm
of these the forearm injuries were associated with multiple- in adults. J Bone Joint Surg Am 1992;74:1068-1078.
23. Stern PJ, Drury WJ. Complications of plate :6..xation of forearm frac-
system trauma involving head injury. Two patients had
tures. Orthop Relat Res 1983;175:25-29.
osteomyelitis. 24. Thompson JE. Anatomical methods of approach in operations on the
• The surgeon must be aware of the DRUJ and PRUJ dislo~a­ long bones of the extremities. Ann Surg 1918;68:309.
tion associated with either an isolated or both-bone forearm 25. Trousdale RT, Linscheid RL Operative treatment of malunited frac-
fra~ture. tures of the forearm. J Bone Joint Surg Am 1995;77A:894-902.
- Reduction and Stabilization
Chapter 5 of the Distal Radioulnar Joint
Following Galeazzi Fractures
f Michael R. Boland

DEFINITION The capsule is relevant only when it is thickened, causing

a contracture and limitation in forearm motion.12
• In 1934 Galeazzf described a fractul'e of the junction of the
Considerable incongruity exists between the curvature of
middle and distal thirds of the radius and called attention to
the ulna head and sigmoid notch, which, along with the
the associated dislocation or subluxation of the distal radioul-
weak capsule, results in an inherently lax joint.
nar joint (DRUJ).
• The triangular fibrocartilage is a specialized structure, part
• Garcia-Elias and Dobyns8 divided DRUJ dislocations into
meniscus (to allow compression accommodating the relative
three types:
shortening of the radius in pronation) and part ligament. It has
Type 1: Pure soft tissue dislocations
palmar and dorsal fibrous thickenings known as the palmar
Type IT: Intra-articular fracture dislocations where there is
and dorsal radioulnar ligaments. These attach to the distal pal-
a fracture involving the joint surface of the sigmoid notch of
mar and dorsal rims of the sigmoid notch as separate bundles,
the radius
and have superficial fibers that attach to the ulna styloid and
Type Ill: Extra-articular DRUJ fracture dislocations for
deep fibers that criss-cross to fonn a weave as they attach to the
foveal fossa of the distal ulna adjacent to the head. These liga-
Type m fracture-dislocations can be subdivided as follows:
ments, along with the distal aspect of the interosseous mem-
ma: abnormal joint surface orientation; usually involve
fractures of the distal two thirds of the radius without brane, are the most important primary stabilizers of the DRUJ.
During rotation, the deep interdigitating fibers create a
complete longitudinal disruption of the forearm
screw home mechanism, similar to the cruciate ligaments of
mb: radioulnar length discrepancy; fractures of the dis-
tal two thirds of the radius with complete longitudinal the knee.
In pronation the deep fibers of the dorsal radioulnar liga-
disruption of the forearm; also known as Essex-Lopresti
ment are taut and the superficial fibers are lax, whereas the
superficial fibers of the palmar radioulnar ligament are taut
• In this chapter, the term Gakaui fracture-dislocation refers
and the deep fibers are lax.10
to a type rna (extra-articular) fracture of the distal two thirds
The opposite is true in supination. Avulsion of the foveal
of the radius with any disruption at all of the congruency of
attachment is common in Galeaui injuries.
the DRUJ due to soft tissue injury.
• Management of the fractured radius is discussed elsewhere
(see Chaps. HA-8 to HA-13). A fracture of the ulna styloid PA1HOGENESIS
commonly is associated with a distal radius fracture. Reduction • The most common mechanism of injury is an axial load in
and .6xation of this fractul'e is covered in Chapter HA-14. pronation, associated with wrist hyperextension.
• Acute dislocations of the DRUJ also can occur in supina-
ANATOMY tion. This usually happens after a fall with a rotating body on
• During forearm rotation a complex interaction occurs be- an outstretched hand, but also can occur in the workplace
tween the radius and the ulna. when the forearm is twisted by rotating machinery.8
From about 50 degrees pronation to 50 degrees supina- • The direction of force is radial to ulnar and proximal to dis-
tion there is a nearly pure rotation of the radius around the tal, through the radius fracture down the interosseous mem-
ulna, with the center of rotation through the middle of the brane, and through the DRUJ.
ulna head. The ulna moves out of the way of the radius by The DRUJ zone of injury includes the capsule, avulsion
virtue of a 9-degree varus-valgus motion that occurs at the of the foveal attachment of the palmar and dorsal radioul-
elbow. nar ligament, and tear of the extensor carpi ulnaris (ECU)
At 50 degrees supination or pronation, a translational subsheath.
slide of the radius occurs on the ulna at the DRUJ.
In full pronation the radius slides volar, making the ulna NATURAL IHSTORY
head prominent dorsally. The opposite takes place in full • Hughston/ in 1957, brought attention to the poor outcome
supination. of these fracture-dislocations without surgical intervention.
• The head of the ulna is the keystone of the DRUJ. It is flat- The criteria used for a per.fea result were very strict, leading
tened distally adjacent to the triangular fibrocartilage disc to a judgment of poor results in 92% of cases. This injury
and rounded radially articulating with the sigmoid notch of complex has been termed "the fracture of necessity," meaning
the radius. The sigmoid notch of the radius is only mildly open reduction and internal fixation of the radius is necessary
concave but is functionally deepened by a horseshoe-shaped for a good result.22
labrum. A flimsy, somewhat loose capsule attached to this • Mikic15 drew attention to the significance of the DRUJ in-
labrum allows the nearly 180 degrees of rotation required of jury. He advocated reduction and percutaneous K-wire fi.xa.
the forearm. tion, noting poor results otherwise.


• Experiments have shown that with an artificial osteotomy of It is important to elicit information regarding the degree
the radius, up to 5 mm of radial shortening occurs.18 Shortening of energy associated with the injury. A fall off a ladder from
of more than 10 mm does not oa:ur unless both the interosseous a height or from a roof is associated with much greater
ligament and the triangular ligament are S&tioned. energy than a ground-level fall.
• Alexander and Lic:htman2 added another subcategory of In industrial accidents, the worker will tend to use techni-
Galeazzi. injury, those in which dosed reduction cannot be cal jargon in referring to machinery, but the examiner must
achieved. The natural history of injuries in this subcategory obtain a layman's description of the machinery and get an
depends on the recognition and appropriate management of accurate idea of the force the machinery wiU generate.
neurologic and vascular complications, in addition to the ade- Any motor vehicle accident is associated with high energy.
quacy of reduction and the degree of DRUJ instability. Any crushing component to the injury must be elicited.
• The DRUJ component of Galeazzi. fracture dislocations, • Initially, the fracture pain may overwhelm both the patient
after anatomic reduction and fixation of the radius, can be and the examiner. Reassessment of the patient following a
considered simple (ie, able to be reduced closed) or complex radiograph showing a radius fracture in the presence of an
(ie, requiring open reduction).19 Once reduced, the DRUJ is re- intact ulna should direct the examiner to the DRUJ as a site
examined and judged stable or unstable. of pathology.
• The patient must be asked about neurologic symptoms in
PATIENT InSTORY AND PHYSICAL the hand, in particular numbness and tingling in the median
FINDINGS nerve distribution.
• Lister13 stated "nothing influences the eventual recovery of Acute carpal tunnel syndrome and forearm and hand com-
hand function more than the mechanism and the force of the partment syndromes must be ruled out in the Emergency
injury... This is certainly true for forearm injuries. Department.
Accurate anatomic bone anatomy is required for perfect • Forearm swelling and tenderness with dorsal prominence of
functioning of the forearm during rotation. the distal ulna (ie, caput ulna deformity) will be observed.
• Patients with a Galeazzi fracture-dislocation usually present • The entire carpus and the elbow should be palpated to
acutely to an emergency department due to the severity of the rule out any longitudinal forearm injury (ie, Essex Lopresti
pain. injury).
• Three common mechanisms lead to Galeazzi. injuries: falls, • Forearm, wrist, and digital motion often are extremely lim-
industrial accidents, and motor vehicle trauma. ited due to pain.


FIG 1 • Intraoperative distal radioulnar joint (ORUJ) shuck test. The head of the ulna is held with a chuck pinch grip, and the wrist and
distal radius are held with a span grasp with the thumb extended across the wrist joint. The radius is held firmly and the ulna is moved
back and forth in a palmar-dorsal direction. The test is done first in neutral (A), then in supination (B) and in pronation (C).
49 -

Table 1 Shuck Test

Grade Duc:ription PathogennisiJiagnosis Management

I <0.5 em motion at extremes; Probable intrasubstance tearing of eithet' the PRUL Cast in neutral rotation
firm endpoint orDRUL
II >0.5 em motion at extremes; Usually associated with fOYNI awlsion of the TFCC; Cast in midpronation
soft endpoint but no can be confirmed by arthroscopy of the DRUJ and
dislocation repaired. No rupture of the distal interosseous
Ill Reduced joint seen before Rupture of distal aspect of intet'osseous membrane Repair fovealawlsion as for grade II; pin DRUJ
stress, with dislocation of in midsupination.
the DRUJ at extremes
IV Dislocmd jaint • Mushy" feeling on stressing jaint Recludble with rotation, consider malposition
of radius fragments if easily dislcxalable.
If truly mushy throughout forearm rotation, there is inter·
position of soft tissue, and open trNtment is required.

DRill di51alr.JdiDulnar pint; DRUI.. di51alr.JdiDulnar igallll!nt; PRill., proximal radioulnar I9Jment

• A sensory examination using static two-point testing is TFCC disruption is unlikely; more than 1 em indicates in·
the most reliable Emergency Department examination for sen- terosseous membrane disruption.
sation. Vascularity is best assessed by examination of radial Miuo et al16 described a technique for interpreting the lat·
and ulnar pulses together with capillary refill in the fingers. eral wrist radiograph whereby the radial styloid is aligned
Often the fingers are pale in this situation. A needle stick with the center of the lunate and an assessment of the overlap
to the digital pulp should cause bright red bleeding. of the radius and ulna is made. The head of the ulna should
• The .fingers must be passively extended to rule out a foreann be completely obscured by the radius. If only part of the ulna
compartment syndrome. Inability to extend the .fingers combined head is obscured by the radius, then there is subluxation of
with tense forearm swelling are the best indicators of a compart- the head, and if the ulnar head is dearly seen, then the joint
ment syndrome, which if present, necessitates urgent surgery. is dislocated. In the operating room a C-arm image in neutral
• Patients presenting late, in the office, usually complain of forearm rotation is obtained with the radial styloid in the
ulnar-sided wrist pain, pain with activities requiring prono- mid-lunate position to interpret DRUJ subluxation.
supination, and DRUJ instability. In these situations the radius • A CT scan is very useful in measuring the degree of sublux·
often is malunited or there is unrecognized bowing of the ulna. ation or dislocation of the DRUJ. ACT scan in the acute sit·
• The DRUJ is examined initially by direct observation, looking uation can be useful in interpreting the degree of DRUJ
for a caput ulna deformity. Palpation begins at the radial head, congruity, but the test is more often performed in the setting
along the interosseous membrane to the ulnar head. Tenderness of a chronic injury.
at the DRUJ proper is elicited by palpating the head of the ulna This is most reliably interpreted by the radioulnar ratio
with the examiner's thumb and sliding the thumb off the head in (FIG 2), calculated as follows:
a radial direction. Tenderness just distal to the head dorsally is The center of the ulnar head is found using concentric
associated with a dorsal tear of the triangular .6brocartilage com- circles.
plex (lFCC). A volar tear of the TFCC is tender on palpation of A line similar to that used in the epicenter method is
the ulnar head between the FCU and ECU and when the exam- drawn from the dorsal and volar margins of the sigmoid
iner slides his or her thumb distally over the head. notch (line A·B).
• DRUJ laxity is assessed with the elbow .flexed 90 degrees. A line perpendicular to this line is drawn to the center
A shuck test is done on the DRUJ at neutral, full pronation, of the ulnar head (line C).
and full supination (FIG 1), and then compared with the un- The AD:A:B ratio is the radioulnar ratio. The normal
injured wrist. ratios are 0.5 to 0.71 for pronation, 0.42 to 0.58 for neu-
At full rotation, there should be no motion of the radius tral, and 0.19 to 0.55 for supination.
relative to the ulna. At neutral, the DRUJ ligaments are
loose and there is about 1 em of shuck (Table 1).
• Imaging of the patient with a suspected Galeazzi injury con-
sists of plain radiographs of the elbow, forearm, and wrist.
The forearm views help in preoperative planning for fixa-
tion of the radius fracture.
The wrist views help to determine the degree of disruption FIG 2 • Radioulnar ratio method to measure DRUJ subluxation
to the DRUJ. On a posteroanterior (PA) view of the wrist, on a cr scan. See text for details. (Adapted from Lo IK,
the degree of ulna shortening has been shown to differ de- MacDermid JC.. Bennett JD, et al. The radioulnar ratio: A new
pending on which structures are tom at the DRUJ.18 Less method of quantifying distal radioulnar joint subluxation. J Hand
than 5 mm of positive variance of the ulna indicates that Surg Am 2001;26:236-243.)

• MlU shows foveal avulsion injuries wdl and is useful for the A foveal avulsion of the TFCC is noted on the preopera-
assessment of the TFCC. tive MRI scan.
Intraoperative fluoroscopic examination of the DRUJ
DIFFERENTIAL DIAGNOSIS after fracture fixation
• The differential diagnosis of ulnar wrist pain in the presence Intra-operative C-arm assessment includes PA and
of a radius fracture includes: lateral views in neutral rotation. In most cases the DRUJ
Fracture of the ulna: shaft, metaphysis, head, styloid should be reduced following fixation.
Triangular fibrocartilage complex injury. Any of the fol- If increased ulna variance, joint diastasis, or subluxation
lowing structures may be injured: fibrocartilage disc, palmar of the ulna head is seen, the first possibility to consider is a
and dorsal radioulnar ligaments, ulnotriquetralligament, ul- malreduction of the radius fracture.
nolunate ligament, ECU subsheath. Most importantly, instability is determined by intraoper-
Lunotriquetral ligament: isolated and as part of either a ative physical examination after fracture fixation.
perilunate dislocation or a longitudinal wrist Grade I: less than 0.5 em motion at extremes, with a firm
Carpal fractures: triquetrum, hamate, lunate endpoint. Probable intrasubstance tearing of either the
• Essex-Lopresti injury proximal radioulnar ligament or the DRUL. Management
• Monteggia fracture-dislocation is in a cast in neutral rotation.
• Elbow fracture-dislocation Grade II: more than 0.5 em motion at extremes, with a
• Stress and pathologic fractures of the radius soft endpoint but no dislocation. This injury usually is as-
sociated with foveal avulsion of the TFCC, which can
NONOPERATIVE MANAGEMENT be confirmed by arthroscopy of the DRUJ and repaired.
• The only time the radius is not internally fixed is when other The distal interosseous membrane is not ruptured. Cast in
patient factors make such surgery unsafe. midsupination. 3
• In the Emergency Department, the longitudinal injury to the Grade ill: reduced joint prior to stress with dislocation of
forearm should be reduced and hdd in a splint. the DRUJ at extremes. Requires rupture of the distal aspect
The reduction maneuver is performed under conscious se- of the interosseous membrane. Repair the foveal avulsion
dation with the thumb and index fingers placed in finger as in grade II and pin the DRUJ in mid-supination.
traps and 10 pounds of traction applied. Grade IV: dislocated joint. "'Mushy" feeling with stress-
A sugartong or long-arm splint with an interosseous mold ing joint. This joint may be reducible with rotation; con-
is applied. sider malposition of radius fragments if easily dislocatable.
Radiographs must be obtained to confirm reduction. If truly mushy throughout forearm rotation, then there is
• If the DRUJ is reduced, then surgery can be delayed for up interposition of soft tissue, and open treatment is required.
to 2 weeks. If the DRUJ remains dislocated, surgery should be Positioning
performed within 72 hours.
• The patient is positioned supine on the operating table with
This interval allows an MlU or CT scan to be ordered and a hand table, and the affected extremity is abducted at the
interpreted to plan for the operative procedure.
shoulder and extended across the table.
• Options for nonoperative management of the DRUJ after
The hand table is positioned so that it adjoins the main
fixation of the radius are discussed later in this chapter.
table at the levd of the shoulder. When the extremity is ab-
SURGICAL MANAGEMENT ducted 90 degrees, it lies in the mid portion of the table.
• A tourniquet is applied at the mid-humerus levd, and a layer
• The key to the management of a Galeazzi fracture is determi- of towels is placed between the humerus and the arm. A layer of
nation of the degree of injury to the DRUJ. It can be classified padding is placed on the upper arm just proximal to the dhow,
as stable, unstable but reducible, or unstable and irreducible. and the arm is taped firmly to the hand table. This allows trac-
• The following information is considered in deciding whether tion to be applied along the axis of the forearm for arthroscopy.
the DRUJ is unstable: • Following fixation of the radius, finger traps are applied to
If, on the initial pre-reduction PA radiograph, the ulna the long and index fingers, and 10 to 12lb of traction is applied.
variance is more than 5 mm positive
If frank dislocation remains after evaluation of the post- Approach
reduction lateral radiograph using the Mino technique • The DRUJ can be approached using arthroscopy,28 a mini-
(discussed under Imaging And Other Diagnostic Studies) open technique,6 or an open dorsal approach.22


notch of the radius and the flare of the metaphysis of
Arthroscopy of the Distal
the ulna. It is easily palpated with the wrist supinated,
Radioulnar Joint which relaxes the dorsal capsule and facilitates intro-
• A 1.9-mm scope and 2.0-mm shaver are the working in- duction of the trocar and scope sheath.
struments for DRUJ arthroscopy. • The joint is insufflated with about 3 ml of saline (which
• Two principal portals are used. helps as a direction guide), the skin is incised with a
• The dorsal-proximal DRUJ (PDRUJ) portal is located in no. 15 blade, and a hemostat pierces the deep fascia and
the axilla of the joint, just proximal to the sigmoid capsule, followed by scope sheath insertion.

• After initial joint penetration, the scope is w ithdrawn Repair of Foveal TFCC Avulsion
slightly until the sigmoid notch and neck of the ulna are
brought into view. • Diagnostic arthroscopy of the radiocarpal joint may re-
veal a peripheral tear in the TFCC.
• Systematically, the steps of a diagnostic arthroscopy are
• Mid-carpal arthroscopy is performed primarily to evalu-
as follows
ate the integrity of the lunotriquetral ligament.
• Evaluate the sigmoid notch while in supination.
• Look down into the axilla of the joint Ooose bodies
• DRUJ arthroscopy shows the status of the proximal sur-
face of the TFCC and confirms a foveal tear of the TFCC
someti mes hide here).
• The scope is then swept distally over the head of the ulna
• A shaver is introduced through the DDRUJ portal to
and pushed anteriorly between the disc of the TFCC and
d~bride this area (IEOI RG tl), and the mini C-arm is
the seat of the head while relaxing the rotation of the
brought in to confirm position over the fovea.
forearm to neutral.
• Rotate into pronation and visualize the anterior com- • A curette is used to freshen the ulna at the foveal insertion .
partment of the DRUJ. • Using a C-arm and arthroscopic guidance, a 1.8-mm drill
hole is made (TEat FIG te-E).
• Then slightly withdraw the scope and visualize the foveal
• The DDRUJ portal is then enlarged to about 1 em in size
with the drill bit in place (IEOI FIG t F).
• The distal DRUJ (DDRUJ) portal is located just distal
• The deep fascia and capsule are opened in line with the
to the seat of the ulna between the fifth and sixth
incision. A Mitek Mini QuickAnchor (Mitek Products,
dorsal compartments. It is about 5 mm proximal to the
Norwood, ~is inserted into the drill hole (TEOI RG t G).
6R portal.
• The DDRUJ portal allows entry of the scope between • Each suture end is placed through the TFCC. and the nee-
dle is brought out the 6R window made in the radio-
the disc of the TFCC and the head of the ulna.
carpal capsule.
• A 21-gauge hypodermic needle is inserted as a direc-
tion f inder with the scope in the PDRUJ portal. • The suture is then tied, pulling the TFCC back to its
anatomic position.
• A probe can be inserted to stress the undersurface of the
• A DRUJ shuck test is performed to ensure restoration of
TFCC disc and ligament insertion into the fovea.
stability, the wounds are dosed, and a long-arm splint is
• A shaver and other instruments also can be introduced
added in mid-supination.
through the DDRUJ portal.

lEOI ~ 1 • Di~gnostic arthroscopy and distal radioulnar joint (DRUJ) arthroscope-assisted repair of the tri-
angular f1brocart1lage complex (TFCQ. A. Foveal avulsion tear. B. Hand placement and portal position using
1.9-m~ scope and 2:0-~m shaver•. c. Hand ~lacement for drilling before Mitek anchor insertion. D. Position of
the mani-C-arm, ~h1ch 1s bro~gh: 1n to confirm placement of the drill bit In the fovea for insertion of the Mitek
anchor. E. C-~rm 1mage conf~rmang placement of the drill bit at the foveal insertion of the TFCC. F. The distal
~R~! portal1s. opened to about 1 em, and dissection is carried down through the deep fascia in line with the
1nc1S1on. Care 1s taken to avoid the dorsal branch of the ulnar nerve. (continued)

TEat FIG 1 • (continued) G. C-arm image confirming

G placement of the Mitek anchor.


Mini-Open Approach • The 6R portal also can be enlarged to see the distal aspect
of the TFCC disc. This gives the surgeon good visualization
• In the mini-open approach, a diagnostic arthroscopy of
of both surfaces of the TFCC disc and aSISOCiated ligaments.
the radiocarpal joint is carried out.
• The 6R portal should be made in a longitudinal orienta-
tion. This is a guide for creation of a longitudinal 2- to Repair of Foveal TFCC Avulsion
3-cm incision incorporating the 6R portal. • The avulsed TFCC is identified and d~brided.
• The incision usually is about 5 mm distal to the 6R • The ulnar fovea is roughened with a curette and drilled
portal and 2 em proximal. with a 1.8-mm bit, after which a single Mitek Mini
• The dorsal branch of the ulnar nerve is found in the soft QuickAnchor (Mitek Products, Norwood, MA) is inserted
tissues at the distal end of the incision and is preserved. into the drill hole.
• The deep fascia is incised in line with the incision. • The torn ulnar border of the TFCC is then advanced and
• A 21-gauge needle is inserted through the capsule of the sutured down to the ulnar fovea ('IEat FIG 2}. The su-
DRUJ into the interval between the head and the proxi- ture on the Mitek Quick Anchor is double ended. Each
mal edge of the TFCC. needle is passed from a proximal to distal direction
• The joint capsule is incised from just proximal to the TFCC
disc to the metaphysis of the ulna.
about S mm apart,. and then the needles are cut off and
the sutures tied within the radiocarpal joint. I use a on~
• A 21-gauge needle is then inserted just distal to the TFCC handed suture-tying technique. No additional suturing is
disc into the radiocarpal joint. necessary.
• The radiocarpal joint capsule is incised transversely about • The capsule, retinaculum, and skin are closed, and a ster-
6 or 7 mm (not quite to the lunate). ile dressing and long-arm splint are applied.

TEat FIG 2 • Sotereanos triangular fibrocartilage complex re-

pair. The technique involves a 3-cm incision centered on the
distal aspect of the head of the ulna. Small windows are cre-
ated in the capsule of the DRUJ and the radiocarpal joint, and
the foveal tear of the TFCC is identified. (continued)
53 -

'IEat FIG 2 • (continued) C. The TFCC is Iifted and the fovea cleared of soft tissue debris. A bone anchor (usually a 2-Q suture
mini-Mitek} is placed in the head of the ulna at the fovea. D. The sutures are passed through the TFCC. E. The sutures are tied,
repairing the TFCC back to its foveal insertion.


Two-Window Exposure of the DRUJ • At the level of the deep fascia the soft tissues are
swept off the fascia in the region of the ulna head
• The forearm is pronated and extended at the elbow.
(IECH FIG 38) .
• A dorsal incision is made beginning 3 em distal to the
ulnar styloid.
• The distal aspect of the antebrachial fascia and the
proximal SO% of the extensor retinaculum are incised
• The incision is carried proximally at 45 degrees to the
longitudinally between the EDM and ECU tendons, and
long axis of the forearm in a radial direction until it
an ulnarly based flap is created (IEat FIG 3().
reaches the dorsal aspect of the radius at the sigmoid
• A 21-gauge needle can be inserted to assess the prox-
imal and distal margins of the TFCC disc.
• At this point it is continued proximally, longitudinally
down the forearm for about 7 em (IEat RG 3A).
• The soft tissues are spread, taking care to preserve the
dorsal sensory branch of the ulnar nerve, which passes
onto the dorsum of the hand about 1 to 2 em distal to
the ulna styloid.


TEat FIG 3 • Open dorsal DRUJ approach.

A. Marker of initial incision. The incision is made
3 em distal to the ulnar styloid at a 45-degree
angle toward the sigmoid notch, then continued
parallel to the interosseous interval proximally
up the forearm. B. The dissection is taken down
to the deep fascia. On the fascia, the fifth com-
partment is clearly visualized. C. The deep fascia
is opened with an L shape along the border of
the fifth compartment and the proximal edge of
c the extensor retinaculum. (continued)

1Eat FIG 3 • (continued) D. The

dorsal capsule of the DRUJ and
periosteum of the distal ulna
are opened longitudinally from
the proximal edge of the TFCC.
E. A second window is created
ulnar to the ECU tendon from
the styloid. The length of this
D E window usually is 2 to 3 em.

• The capsule of the DRUJ is incised proximal to the TFCC • Two drill holes are made with 0.045-inch K-wires at a
disc to the point where it blends with the periosteum 45-degree angle about 1 em from the articular surface
over the metaphysis of the ulna ClEat FIG 3D). of the head of the ulna, directed from the medial cor-
• The ulnocarpal joint capsule is opened to the lunotri-
tex of the ulna and exiting at the ulnar fovea •
• The holes are parallel, beginning 1 em apart, and
• Both capsular incisions are in line with retinaculu~ converge toward the fovea.
fascial incision. • A transverse arthrotomy is made in the radiocarpal
• The TFCC disc and associated ligaments, the DRUJ, and capsule at the distal edge of the 'TFCC disc.
ulnar aspect of the radiocarpal joint can be inspected. • Three separate loops of a 3.0 braided nylon suture are
• A second, more ulnar window to the distal ulna can be
made by sharp dissection to the ulna styloid and carried
passed through one hole, through the peripheral TFCC.
and back out the other hole, and tied individually over
proximally parallel with the ECU sheath (IECH FIG 3E). the medial ulna.
• care is taken to avoid opening the EDM and ECU • The capsulotomy incisions are dosed first, then the reti-
sheaths. naculum is closed, and finally the skin is dosed.

TFCC Repair
• Two 0.062-inch K-wires are placed through the ulna and
into the radius in a neutral position (IEat FIG 4).
• The peripheral foveal avulsion is d~brided, and the fovea • The capsule, retinaculu~fascia, and skin are dosed in
freshened with a curette. layers.

3 3.0 sutures

lECH FIG 4 • Repair of the TFCC. A. Three 3.0 nonabsorbable sutures are placed through the retracted medial
TFCC and passed through holes at the medial base of the ulna styloid. B. Before tightly suturing the TFC to the
prepared trough, the distal radioulnar relationship is secured by two percutaneous 0.062-inch K-wires placed
through the ulna into the radius in neutral position. must be exercised to avoid injury to the DRUJ.


• Rarely, the TFCC can be completely shredded is excised and reconstructed using a palmaris
in a high-energy injury. In this instance the TFCC graft.


Assessment of DRUJ • The initial PA view of the wrist will show more than 5 mm of ulna shortening. The initial lateral
instability radiograph will show dorsal subluxation of the ulna. A preoperative MRI scan will show increased
signal (white} in the TFCC and an avulsion of the TFCC at the fovea. A positive shuck test will be
present intraoperatively (this is the most important test}. A subluxed ulna will be seen in the lateral
intraoperative C-arm view.
Irreducible DRUJ after • Consider lack of anatomic reduction of the radius. Radial bow will not have been fully restored.
radial fixation This is especially prevalent in the segmental or comminuted radius. If convinced the radius is
anatomic, then explore the DRUJ with open technique. The ECU and the extensor digitis minimi of
the ulnar styloid are commonly in the joint.
Difficulty interpreting • Ensure forearm is in full supination or pronation. There should be no motion at the DRUJ between
DRUJ shuck. test the radius and the ulna. If there is any motion then there is likely to be instability, and at the very
least, a long-arm cast in mid-supination should be applied.
Difficulty in getting into • Reduce traction to about 5 lb. Use a 1.9-mm scope, and use a 21-gauge needle and saline to
the joint for DRUJ insufflate the joint. Place the forearm in supination. Push the trocar into the neck of the ulna
arthroscopy (ie, between the radius and ulna}.

POSTOPERATIVE CARE was that rigid internal fixation is necessary for the disloca-
tion as wdl as the fracture.
• All of the following proto~ols assume that rigid and stable • So-called "isolated" fractures of the radial diaphysis, where
fixation of the radius fra~ture has been obtained. there is less than 5 mm of positive ulna variance, are more
• Stable DRUJ common than true Galeazzi fractures. Fractures without iden-
The patient is pla~ed in a sugar-tong splint for 2 weeks, tifiable radioulnar disruption can be treated without specific
and is given a Carter block arm pillow for strict elevation treatment of the DRUJ and with immediate mobilization.23 In
and enoouragement of fmger and thumb motion. this situation, patients with anatomic fracture redu~tion have
At 2 weeks, the patient returns to the offi~e for suture and minimal sequelae and better or equal functional results than
splint removal. patients with imperfect reduction. 20
The patient is referred to a hand therapist for a~tive, pas-
In a series of 50 Galeazzi ~ture dislocations treated by
sive, and gentle resisted motion up to 10 lbs resistan~e. early open reduction and internal fixation, Mohan et al17
Motion of all joints from the elbow distally is en~ouraged.
found, at 1 year, 40 good, 8 fair, and 2 poor results. Their ron-
Further resistance and weight bearing depend on union of elusion was that early open reduction and rigid internal fixa-
the radius.
tion re-establishes the normal rdation of the fractured frag-
Usually, union o"urs by 6 weeks and restrictions are lifted. ments and the DRUJ without repair of the ligaments. Thus, in
Return to work status depends on the levd of repetition many situations, ligament repair is unnecessary. (However, in
and lifting required by the patient's job. Mohan et al's series, 1 in 5 had a less than good result.)
• Rehabilitation following bone andor fixation of a foveal • Rettig and Raskin/1 in a more recent series, found that the
avulsion of the TFCC and full palmaris graft reconstruction
more distal the fra~ture the greater the likdihood of DRUJ dis-
Long-arm splint, dbow at 90 degrees, forearm in mid- ruption. In this series, 12 out of 22 fractures within 7.5 em of
supination, wrist neutral; fingers not included
the midarticular surface of the distal radius had intraoperative
At 2 weeks the patient returns to the office for suture re- DRUJ instability, whereas only one of 18 more proximally
moval and the arm is placed in a cast in the same position.
were unstable. Their conclusion was that a high index of sus-
Four weeks later (ie, 6 weeks postoperativdy), the cast is picion, early recognition, and acute treatment of DRUJ insta-
removed and active gentle passive motion is begun to all
bility will avoid ~hronic problems in this ~omplex injury.
joints from the elbow distally. • This high index of suspicion will lead to the recognition
At 12 weeks postoperatively, graduated lifting activity is that dislocations of the DRUJ associated with fractures of the
begun, and ~ontinues for 6 more weeks. forearm often are irreducible.5 These have been termed
At week 18 all restrictions are removed. "complex" DRUJ dislocations: dislocations chara~terized by
• Open foveal repair and K-wire obvious irreducibility, recurrent subluxation, or "mushy" re-
At 6 weeks, K-wires are removed. du~tion ~aused by soft tissue or bone interposition.
Begin protoool as for bone andor fixation.
• With the advent of internal fixation of the radius, most
Galeazzi fractures are predictably reduced. It is mandatory
OUTCOMES that the DRUJ be evaluated and managed ac~ording to the de-
• The key to a suc~essful ou~ome of acute Galeazzi fracture- gree of instability to the joint. A high index of suspicion means
dislocations is accurate reduction and rigid fixation of the the outcome is associated more with the degree of energy in-
radius along with recognition and appropriate repair or re~on­ volved in the injury than with any inability on the part of the
struction of the disrupted DRUJ. 15 Conservative management surgeon to care for the DRUJ appropriately.
seems to be successful only in ~hildren.
In a classic article by Mikic, 15 conservative management COMPLICATIONS
in adults resulted in failure in 80% of cases. The results of • The most common compli~ation of a Galeazzi fracture is
operative treatment were mud better, and the conclusion malunion of the radius and residual DRUJ instability/'' due to

malrotation and residual angulation of the radial shaft. 8 In 7. Galeazzi R. Uber ein Besondcres Syndrom bei Verltzunger im Bereich
der Unteraumknochcn. An:h OrthoUnfallchir 1934;35:557-562.
most ~ases a DRUJ-stabilizing tenodesis ~annot restore the
8. Garcia-Elias M, Dobyns J. Dorsal and palmar dislocations of the dis-
joint, and a ~orr~tive osteotomy is required. 4 tal radioulnar joint. In Cooney WP, Linsdu:id RL, Dobyns JH, eds.
A preoperative three-dimensional cr r~onstruroon of the The Wrist: Diagnosis and Operative Treatment. St. Louis: Mosby,
bones of the entire forearm is very helpful in this situation. 1998.
• Management of a missed dislo~ation5 depends on the timing 9. Hughston JC. Fracture of the distal radial shaft: Mistakes in manage-
of presentation. ment. J Bone Joint Surg Am 1957;39A:249-264.
If less than 10 weeks after the injury, open redu~tion and 10. Ishii S, Palmer AK, Werner FW, ct alAn anatomic study of the liga-
mentuus structure of the triangular nbrocartilagt: complex. J Hand
repair usually is possible. Surg Am 1998;23:977-985.
Mter 10 weeks, re~onstru~tion with ligament grafting is 11. Kleinman WB. Repair of chronic peripheral tcarslavulsions of the tri-
required. angular fibrocartilage. In Blair W, ed. Techniques in Hand Surgery.
• The inciden~e of radius nonunion is dire~dy related to the Baltimore: Williams & Wilkins, 1996.
number of s~ews used: the rate is four times higher for bones 12. Kleinman WB, Graham TJ. The distal radioulnar joint capsule:
plated with four s~rews rompared to those plated with five or Clinical anatumy and role in posttraumatic limitation of forearm mo-
tion. J Hand Surg Am 1998;23:588-599.
more s~ews.Z 6
13. Lister G. The Hand: Diagnosis and Indications. Edinburgh: Churchill
• Radioulnar synostosis may be seen, parti~ularly in patients Iivingstone, 993:2.
with multiple system trauma involving head injury. 14. Lo IK, MacDcrmid JC, Bennett JD, et al. The radioulnar ratio: A new
• Osteomyelitis may develop in open and ~rush injuries. method of quantifying distal radioulnar joint subluxation. J Hand
• Nerve palsies, including the anterior interosseous and ulna Surg 2001;26:236-243.
nerves, have been associated with Galeazzi fra~tures,24• 25 and 15. Mikic ZD. Galcazzi Fracture-Dislocations. J Bow: Joint Surg Am
a~ute ~arpal tunnel syndrome is a ~ommon rompli~ation, par-
16. Mino DE, Palmar AK, Lcvinsobn EM. The role of radiography and
ti~ularly in ~rush and high-energy injuries.
compurerizcd tomography in the diagnosis of subluxation and
• Compartment syndrome of the forearm also is a known dislocation of the distal radioulnar joint. J Hand Surg Am 1983;
~omplkation. 8:23-31.
• Osteoarthritis of the DRUJ is a long-term romplkation and 17. Mohan K, Gupta AK, Sharma J, eta!. Inremal fixation in 50 cases of
~an be managed by arthro~opy, interposition arthroplasty, ulna Galeazzi fracture. Acta Orthop Scand 1988;59:318-320.
shortening, ulna head repla~ement, or total joint arthroplasty, 18. Moore TM, Lester DK, Sarmiento A. The stabilizing cf~ct of soft-
tissue constraints in artificial Galeazzi fractures. Clin Orthop Rclat
depending on severity of the injury and age of the patient. Res 1985;194:189--194.
• Compli~ations in Galeazzi fra~ture-dislo~ations ~an be min- 19. Nicolaidis SC, Hildreth DH, Lichtman DM. Acute injuries of the dis-
imized with attention to detail, in parti~ular a~~urate anatomi~ tal radioulnar joint. Hand Clin 2000;16:449-459.
redu~on of the radius fra~ture, thorough assessment and re- 20. Rcclding FW. Unstable fracture-dislocations of the forearm (Monteggia
pair of instability of the DRUJ, and appropriate postoperative and Galcazzi lesions). J Bone Joint Surg Am 1982;64A:857-863.
rehabilitation. 21. Rettig ME, Raskin KB. Galeazzi fracture-dislocation: A new treatment-
oriented classification. J Hand Surg Am 2001;26:228-235.
22. Richards RR, Corley FG. Fractures of the shafts of the radius and ulna.
REFERENCES In Rockwood CA, Green DP, Buckholz RW, ct a!, ods. Rockwood and
1. Adams BD, Berger R. An anatomic reconstruction of the distal ra- Green's Fractures in Adults, ed 4. Philadelphia: lippincott-Raven,
dioulnar ligaments for posttraumatic distal radioulnar joint instabil- 1996.
ity. J Hand Surg 2002;27:243-251. 23. Ring D, Rhim R, Carpcnrer C, ct a!. Isolated radial shaft fractures
2. Alexander AH, Iichtman DM. Irreducible distal radioulnar joint occur- are more common than Galeazzi fractures. J Hand Surg Am 2006;
ring in a Gabzzi fr~ report. J Hand Surg Am 1981;6: 31:17-21.
258-261. 24. Saitoh S, Scki. H, Murakami N, ct a!. Tardy ulnar tunnel syndrome
3. Boland MR, Bader J, Pienkowski D. Joint reaction forces at the dis- caused by Galeazzi fracture-dislocation: neuropathy with a new path-
tal radioulnar joint: A biomcchanical model presentation at the ASSH omcchan.ism. J Orthop Trauma 2000;14:66-70.
Annual ~eting 2006, Washingtun, DC. 25. Stahl S, Freiman S, Volpin G. Anterior interosseous nerve palsy asso-
4. Bowers WH Instability of the distal radioulnar articulation. Hand ciated with Galeazzi fracture. J Pcdiatr Orthop B 2000;9:45-46.
Clin 1991;7:311-327. 26. Stern PJ, Drury WJ. Complications of plare fixation of forearm
5. Bruckner JD, Lichtman DM, Alexander AH. Complex dislocations of fractures. Clin Orthop Rdat Res 1983;175:25-29.
the distal radioulnar joint. Recognition and management. Clin 27. Strehle J, Gerber C. Distal radioulnar joint function after Galcazzi
Orthop Relat Res 1992;275:90-103. fracture-dislocations treated by open reduction and intcmal plate
6. Chow KH, Sarris IK, Sotereanos DG. Suture anchor repair of ulnar- fixation. Clin Orthop Relat Res 1993;293:240-245.
sided triangular fibrocartilage complex tears. J Hand Surg Br 2003; 28. Whipple 11.. Arthroscopy of the distal radioulnar joint. Hand Clinics
28:546-550. 1994;10:589-592.
- Corrective Osteotomy
Chapter 6 for Radius and Ulna
Diaphyseal Malunions

Vimala Ramachandran and Thomas F. Varecka

DEFINITION The shaft possesses a gentle bow, with the volar surface
concave and the dorsal and lateral surfaces convex.1
• Malunion of the radial or ulnar shaft can lead to pain, loss
of motion, loss of strength, and instability at the level of the Schemitsch and Richards9 devised a formula that locates
the apex and defines the magnitude of the radial bow for
wrist or elbow.
each individual (FIG 2).
• Malrotation, angulation (with narrowing of the in-
terosseous space between the radius and ulna), shortening. and • Ulna1
The ulna is a long bone that has a triangular cross section
loss of the radial bow have been shown in various studies to
in the proximal two thirds and a circular cross section distally.
lead to decreased functional outcomes.4 •5.9•10•12
It possesses three surfaces: anterior, posterior, and medial.
• Arthritis has been reported at the level of the proximal ra-
The proximal half of the shaft is slightly concave volarly.
dioulnar joint (PRUJ) with lon~tanding malunions, although
The distal half is relatively straight.
the distal radioulnar joint (DRUJ) is most commonly affected
• The PRUJ consists of the radial head, the radial notch, the
by forearm malunions.11
annular ligament, and the quadrate ligament.
ANATOMY • The DRUJ consists of the sigmoid notch, the ulnar head, the
• The forearm can be thought of as a ring, connected at the dorsal and volar radioulnar ligaments, the extensor carpi ul-
PRUJ, the interosseous membrane, and the DRUJ (FIG 1 ). naris (ECU) subsheath, and the triangular fibrocartilage com·
plex (lFCC).
• Force transmission occurs through the interosseous mem-
brane from the radius distally to the ulna proximally.
• Radius
The radius lies parallel to the ulna in supination. With • Both-bone forearm fractures occur through a variety of
pronation, it rotates around the ulna while the ulna main- mechanisms, including indirect trauma (such as falls on an
tains its position throughout forearm rotation. outstretched arm or motor vehicle accidents) and direct
The radius shaft is triangular in cross section, with the trauma (such as blows to the forearm).
apex toward the attachment of the interosseous membrane.
It contains three surfaces: anterior, lateral, and posterior.

FIG 2 • Measurement of the location and magnitude of the ra-

dial bow. The distance y represents the length of the radius as
measured from the bicipital tuberosity to the ulnar aspect of
the radius. Line a, drawn perpendicular toy from the point of
greatest curvature of the radius, represents the magnitude of
Supination Neutral Pronation the radial bow (expressed in millimeters). The distance x repre-
sents the length of the radius from the bicipital tuberosity to
FIG 1 • Lateral projection of the radius and ulna. Relationship the point where a intersects y. The location of the radial bow is
of the interosseous membrane to the radius and ulna during calculated by x/y x 100. (Adapted from Schemitsch EH, Richards
forearm rotation. The fibers of the interosseous membrane are RR. The effect of malunion on functional outcome after plate
longest with the forearm in neutral position and shorten in fixation of fractures of both bones of the forearm in adults. J
both pronation and supination. Bone Joint Surg Am 1992;74A:1068-1078.)


• Acute fractures treated dosed or with intramedullary nailing Pain with compression of the radius and ulna at the level
techniques are more likely to heal malwlited.7•8 of the DRUJ may also be indicative of DRUJ instability or
• Radius malunions have a greater effect on forearm rotation arthritis (DRUJ compression test).
than ulna malwlions.10•12 • Neurovascular examination
• A torsional deformity of greater than 30 degrees in the ra· The examiner should check for anterior interosseous nerve
diusleads to significant loss of forearm motion.4 (OK sign), posterior interosseous nerve (thwnb extension),
• Changes in the length-tension curve of the interosseous and ulnar nerve (abduction-adduction of fingers) function.
membrane may also accoWlt for loss of rotation.12 Inability to perform tasks identifies nerve injury.
• Fifty degrees of supination and 50 degrees of pronation are STUDIES
needed for activities of daily living.6 • AP and lateral radiographs of both forearms should be
• Patients with Wltreated forearm malwlions may experience obtained (FIG 3.A,B).
loss of forearm rotation, PRUJ or DRUJ instability, wrist pain, Both the bicipital tuberosity and the radial styloid should
los.s of strength, and arthritis at the PRUJ.11 The severity of the be visualized for the film to be adequate.
symptoms depends on the degree of malwlion and the corre· The degree of angulation and comminution can be calcu-
sponding alteration in degree and location of the bow of the lated from these films.
radius. Contralateral forearm films provide a comparison for the
Malwlions of 10 degrees or less lead to less than a 20- amount of shortening as well as for the location and angle
degree loss of forearm rotation and hence are clinically of the radial bow.9
Angular malaligwnent of more than 20 degrees in the ra·
dius or ulna results in clinically significant loss of motion.
Greater than 15 degrees of malalignment leads to inability
to perform activities of daily living.5•7•1o
• Patients with greater than 15 degrees of malalignment or
los.s of the radial bow will have clinically significant loss of
motion and strength if left Wltreated.
• The preoperative evaluation for patients with forearm malu-
nions includes a detailed assessment of the patient's functional
limitations as well as documentation of elbow and wrist range
of motion, the supination-pronation arc of the forearm, and
the stability of the PRUJ and DRUJ.
• Physical examination
The skin is inspected for scarring or previous incision sites.
Muscle bulk and tone are examined.
The wrist, elbow, and malunion site are palpated for ten·
• Range of motion
The flexion-extension arc of the elbow is measured with
the shoulder at 30 degrees of forward flexion.
Rotation of the forearm is ascertained with the humerus A
stabilized against the chest wall and the elbow at 90 degrees
of flexion.
Wrist flexion and extension are determined with the fore·
arm in neutral rotation.
joint loss of motion may indicate location of pathology.
A high degree of motion loss will lead to functional deficits.
Stability of the PRUJ is assessed by palpation during pas·
sive pronation and supination.
The DRUJ is evaluated by stressing the ulna volarly and FIG :J • A.B. AP and lateral radiographs demonstrate a segmen-
dorsally while stabilizing the radius. tal radius shaft fracture resulting in a malunion both proximally
and distally despite open reduction and internal fiXation. Note
Subluxation of the ulnar head or the ECU is evaluated
the loss of radial bow in both direction and magnitude, narrow-
during passive range of motion (ECU subluxation test).
ing of the interosseous space between the radius and ulna, dor-
The piano key test can also be used to assess for an unsta· sal positioning of the distal ulna. and nonunion of the basilar
ble DRUJ. Patients with a positive piano key sign will have ulnar styloid fracture. The patient was unable to supinate to
an ulnar head that shifts volarly with a minimal volarly di- neutral and demonstrated instability at the distal radioulnar
rected force and then reboWlds dorsally once that force is re· joint. C. cr scan demonstrates narrowing of the interosseous
moved, much like a key in a piano. space with heterotopic bone formation.
59 -

• A CT (FIG 3C) scan or MRI can also be obtained to assess Positioning

for malrotation.1 • The patient is positioned supine on the operating table. A
radiolucent hand board is attached to the table, centered on
DIFFERENTIAL DIAGNOSIS the patient's axilla. The affected extremity is then extended
• DRUJ injury or instability and can be positioned for either a volar or dorsal approach to
• PRUJ injury or instability the radius by rotating through the shoulder.
• Injury to the interosseous membrane • The subcutaneous border of the ulna can be visualized by
• Synostosis flexing the arm at the elbow or by placing the arm across the
• Nonunion chest.
• A nonsterile tourniquet may be used on the arm.
• Nonoperative tteatment of malunions depends on the pa- Approac:h
tient's symptoms and includes occupational therapy for strength- • Radius shaft malunions may be approached either volarly or
ening and range of motion, removable off-the-shelf braces, non- dorsally.
narcotic medications, and custom molded DRUJ orthoses. • The volar (Henry) approach is best suited for midshaft and
distal radius shaft malunions.
SURGICAL MANAGEMENT The proximal radius shaft can be approached volarly in
• Operative intervention for forearm malunions depends on this manner; however, injury to the posterior interosseous
the functional limitations of the patient, not the degree of de- nerve (PIN) can occur when dissecting the supinator muscle
fo.rmity apparent on radiographs. off the radius.
• Indications for surgery include loss of forearm rotation that The approach is extensile and can be used to expose not
leads to a functional deficit (rotational arc less than 100 degrees), only the entire length of the radius but also the wrist
DRUJ instability, unacceptable cosmesis, and painful nonunion. joint.3
• Risks to the patient include vascular injury, nerve injury or • The dorsal (Thompson) approach to the radius is used most
parestheaias (spe(:ifically the super.ficial radial nerve), in£~­ commonly for proximal malunions.
tion, nonunion, delayed union, ne<:d for iliac crest bone graft, It provides access to the PIN, allowing the surgeon to iso-
synostosis, loss of motion, and DRUJ instability. late the nerve and retract it out of harm's way for the re-
• Patients treated within 1 year of the initial injury may be mainder of the procedure.
more likely to improve functionally and have a lower surgical This approach may be of value for midshaft exposure of
complication rate.11 the radius, es~ally in the case of a midshaft segmental
• Malunions of the radius and ulna are generally treated with malunion (see Fig 3A,:B).
an open approach. corrective osteotomy of one or both bones, The entire dorsal surface of the radius can be exposed
compression plating, and bone grafting as necessary. through this approach.3
Generally, the more defo.rmed bone is corrected first. If • The ulna is approached along ita subcutaneous border.
after correction of the first bone forearm rotation is stiU The entire length of the ulna can easily be exposed
lacking, an osteotomy is performed on the second bone. through this approach.
If both bones are equally deformed, the ulna is os-
teotomized and provisionally plated first to provide a work-
ing length for the radius.
• Restoration of the radial bow in large part determines func-
tional outcome.
Patients whose radial bow is restored within 1.5 rwn of
magnitude and located within 4.3% of the contralateral
forearm regain 80% of normal motion.
Eighty percent of grip strength is regained if the radial
bow is located within 5% of the contralateral side,!~

• Anatomic realignment of the radius and ulna will not im- •
prove functional deficits if a synostosis or significant scarring 0
and contracture involving the soft tissues has occurred.
Occult injury to or contracture of the DRUJ and PRUJ •
must be identified and treated at the time of surgery. •

Preoperative Planning •
• Radiographs of the affected and contralateral extremity
should be reviewed. A B
A cr scan is helpful to assess for rotational deformity.
FIG 4 • Preoperative planning using AO technique for correc-
• A corre(:tive three-dimensional osteotomy is planned using
tion of the malunion of the case in Figure 3. A. The malunion is
standard AO technique (FIG 4 ).
first sketched out from the preoperative radiographs. B. Each
• The need for corticocanceUous iliac crest bone graft should fragment is then drawn out separately. C. The osteotomy sites
be determined by the degree of shortening. are noted on both the AP and lateral views. The radius is then
• The surgeon should be familiar with t~hniques for ~­ realigned through the planned osteotomy sites and bone graft
struction or stabilization of the DRUJ should it remain unsta- (yellow) is inserted to restore the normal magnitude and loca-
ble after correction of the malunion. tion of the radial bow.


• Landmarks: biceps tendon, brachioradialis (BR}, radial
• Ligate the recurrent radial artery to retract the BR
• Center the skin incision over the malunion site and fol- • Pronate the forearm and release the PT insertion.
low a line that begins lateral to the biceps tendon, con- • Dissect the PT muscle subperiosteally from a lateral to
tinues over the medial edge of the BR, and ends distally medial direction to expose the volar surface of the radius.
at the level of the radial styloid. • To expose the distal radius, the surgical interval lies be-
• The length of the incision depends on the amount of tween the flexor carpi radialis (FCR) and the radial artery.
exposure needed to take down the malunion and • Retract the FCR medially and the radial artery laterally to
plate the osteotomy. expose the flexor pollicis longus (FPL} and the pronator
• To expose the midshaft.. dissect between the BRand the quadratus (PQ).
pronator teres (PT) proximally (IECH FIG 1). • Retract the FPL medially.
• The superficial radial nerve lies on the undersurface • Release the PQ from its radial insertion and dissect the
muscle belly from the volar distal radius.
of the BR and must be protected.

1ECH FIG 1 • Exposure of the radial shaft through the volar approach.
c This approach is best for midshaft and distal shaft malunions.


• Landmarks: lateral epicondyle, tubercle of Lister • Once the nerve is fully mobilized and protected, supinate
• The skin incision is centered over the malunion and fol- the arm and release the supinator from the anterior sur-
lows a gently curved line starting just anterior to the lat- face of the radius in a medial to lateral direction.
eral epicondyle and ending just distal and ulnar to the • To expose the midshaft of the radius dorsally, the abduc-
tubercle of Uster at the wrist (IECH FIG 2A). tor pollicis longus (APL} and the extensor pollicis brevis
• Incise the fascia in line with the skin incision. (EPB) must be mobilized as they cross radially over the
• Dissect between the extensor digitorum communis (EDQ dorsal shaft of the radius.
and the extensor carpi radialis brevis (ECRB) proximally. • Incise the fascia along the inferior and superior borders
• Pronate the forearm. of the two muscles and lift them off the radius.
• Identify the PIN as it emerges from the supinator 1 em • Retract them distally or proximally as needed for ex-
proximal to the distal edge of the muscle (IECH FIG 21). posure ofthe malunion.
• Follow the nerve in a distal to proximal direction
through the supinator, carefully preserving its motor

'IEat FIG 2 • Exposure of the radius through the dorsal ap-

proach. This approach is best for proximal shaft malunions.
A. Skin incision on dorsal surface, running from tip of lateral
epicondyle toward radial styloid. 1. The posterior in-
terosseous nerve is followed through the supinator, with its
I digi!Drum communis interosseous nerve branches preserved.


• Landmark: subcutaneous border of the ulna
• Make a longitudinal incision along the subcutaneous
border of the ulna ClEat FIG 3A).
• Incise the fascia in line with the skin incision.
• Dissect between the extensor carpi ulnaris (ECU} dorsally
and the flexor carpi radialis (FCU) volarly (IEat FIG 31).
• Take care to avoid disrupting the ECU subsheath dis- A
tally over the ulna head.

'IEat FIG 3 • Exposure of the ulna. A. Skin incision along su~

cutaneous border of ulna. B. Dissection is performed between
the extensor carpi ulnaris dorsally and the flexor carpi radialis
volarly. I


• Based on the preoperative scheme, perform the planned • Plate the malunion using a 3.5-mm compression plate and
osteotomy at the site of malunion using a combination AO compression plating techniques (IEat FIG 40-G).
of a water-cooled saw and osteotomies. • Obtain a minimum of six cortices of fixation proximal
• Bring the radius out to length and insert bone graft as
necessary (IEat FIG 4A).
and distal to the malunion.
• In smaller patients, a 2.7 DC plate may be used
• Make a template for plate contouring so as to match the instead•
radial bow (IEat FIG G,C}.

A B c
TEat RG 4 • A. Reduction after osteotomy of the midshaft segmental radius malunion through a volar exposure in the pa-
tient in Figures 3 and 4. Because of the segmental nature of this malunion. fixation was accomplished by plating both
volarly and dorsally. B. A metal template is placed on the volar surface of the corrected radius. C. The template is used to
precisely contour the plate so that when applied, the normal curvature of the radius is restored. (continued)


TEat RG 4 • (continued) D. Plate fiXation. E. Schematic de-

piction of plate and bone graft placement. F.G. Postoperative
radiographs after dual plating of Ute segmental radial shaft
malunion seen in Figure 3. Bone graft was inserted at both
the proximal and distal osteotomy sites for realignment of the
radial bow and near restora~on of radial length. Distal ra-
dioulnar joint instability was treated by ftxation of the ulnar
styloid fracture (using a 0.0620-inch K-wire} and postoperative
immobilization in supination. F G

• After fixation, take the forearm through a full supina- • If the joint is incongruent or arthritic, consider ulna
tion-pronation arc. shortening, matched resection arthroplasty, Darrach re-
• Blocks to motion result from an uncorrected ulnar section, or the Sauve-Kapandji procedure.
malunion, DRUJ incongruenc:y or instability, failure to • Reapproximate tendon insertions. For example, in the
restore the radial bow, synostosis, and soft tissue or case of a volar e:xposure to the distal radius, repair the
interosseous membrane scarring and contracture. PQ to its radial insertion using absorbable suture.
• If an ulna osteotomy is required, the plate can be placed • aose the subcutaneous tissues and skin.
on the volar surface of the ulna or on its subcutaneous • To minimize the risk of compartment syndrome, do
border in the manner detailed above. not close the fascia.
• If the DRUJ is unstable, consider palmar capsular reefing, • Apply a volar splint.
reconstruction with tendon graft, fixation of an ulnar • In patients with concomitant DRUJ instability, a
styloid base nonunion, or pinning of the joint in full sugar-tong splint with the forearm in full supination
supination. is placed.


Indications • Assess DRUJ stability.
• Determine that lack of motion is not due to soft tissue contracture, synostosis, or interosseous membrane scarring,
for which realignment of the malunion would not improve motion.
Osteotomy • Obtain contralateral forearm films to determine location and magnitude of radial bow.
• Obtain CT or MRI if concerned for rotational malunion.
• Perform detailed preoperative drawings to determine the ideal location for the osteotomy, the degree and direc-
tion of correction required, and the need for bone graft.
• Obtain consent for bone graft.
Approach • If a volar approach to the proximal radius is chosen, avoid injury to the PIN by careful subperiosteal stripping of the
supinator from the radius and gentle retraction of the supinator laterally to prevent a traction neurapraxia. Avoid
placing a retractor around radial neck as this can compress the PIN (or cause a traction injury of the nerve). Gently
retract the superficial radial nerve and radial artery.
• Protect the PIN during dissection when approaching the proximal radius dorsally. The nerve lies directly on bone
dorsally, opposite of the bicipital tuberosity in 25% of patients. Avoid trapping the nerve between the plate and
bone when placing a plate proximally.
DRUJ • Determine the cause of instability of the DRUJ once malalignment is restored.
• Perform a procedure that addresses the precise cause of the DRUJ instability.


• In a ~ompliant patient with se~ure fixation, the splint may • A 48% complication rate was noted m Trousdale and
be removed 5 to 7 days after surgery and range-of-motion ex- Linscheid's study. 11
ercises initiated. • Infection
A removable orthosis is worn for the next 4 to 5 weeks. • Wrist pain
• Strengthening exercises are begun 6 weeks after surgery. • Loss of motion
Resistive strength training is delayed until radiographi~ • Heterotopic ossification
evidence of healing is present (usually 8 to 12 weeks postop- • DRUJ instability
eratively). • Delayed union or nonunion
• Normal activities are resumed when a solid union is present. • Superficial radial nerve paresthesias
• Plates are generally not removed in adults.
• If concomitant DRUJ instability is present: REFERENCES
A Munster cast is applied at the first postoperative visit. 1. Botte M. Skeletal anatomy. In: Doyle J, Batte M, eds. Surgical
The forearm is held in full supination for 6 weeks. Anatomy of the Hand and Upper Extremity. Philadelphia: Lippincott
Finger range-of-motion and elbow flexion-extension ex- Williams & Wilkins, 2003:3-91.
ercises are begun at the first postoperative visit. 2. Dumont CE, Pfirrmann CW, Ziegler D, et aL Assessment of radial
At 6 weeks, any pins in the DRUJ are removed, and and ulnar torsion profiles with cross-scctiooal magnetic n:sonance
imaging. J Bone Joint Surg Am 2006;88A:1582-1588.
supination-pronation exercises are initiated. 3. lbe fon:ann. In: Hoppenfdd S, DeBoer P, eds. Surgical Exposures in
Orthopaedics, 2nd ed. Philadelphia: Lippincott Williams & Wilkins,
OUTCOMES 1994:117-146.
• Trousdale and Lins~heid retrospectively reviewed 27 pa- 4. Kasten P, Krefft M, Hesselbach J, et aL How does torsiooal deformity
tients with corrective osteotomies for forearm malunions. of the radial shaft influence the rotation of the forearm? A biome-
chanical study. J Orthop Trauma 2003;17:57-60.
Indications for surgery included loss of rotation (20 patients),
5. Matthews LS, Kaufer H, Garver DF, et al. lbe effect on supination-
unstable DRUJ (6 patients), and cosmesis (1 patient)Y pronation of angular m alalignment of fractures of both boues of the
Of the six patients with DRUJ instability, five had stable forearm. J Bone Joint Surg Am 1982;64A:14-17.
wrist joints at follow-up. Three patients were stabilized with 6. Morrey BF, Askew LJ, An KN, et al. A biomechanical study of normal
correction of the deformity alone, and three required reefing functional elbow motion. J Bone Joint Swg Am 1981;63A:872-877.
of the palmar capsule and temporary pinning of the DRUJ 7. Sarmiento A, Ebramzadeh E., Brys D, et aL Angular deformities and
with Kirschner wires (K-wires). forearm function. J Orthop Res 1992;10:121-133.
8. Schem:itsch EH, Jones D, ~nley MB. A comparison of malreduction
The patient who underwent the pro~edure for ~osmesis after plate and intramedullary nail fixation of forearm fractures. J
lost 10 degrees of rotation but was happy with the overall Orthop Trauma 1995;9:8-16.
appearan~ and function. 9. Schem:itsch EH, Richards RR. 1be effect of malunion on functiooal
The age of the patient at the time of injury, location of the outcome after plate fixation of fractures of both bones of the forearm
malunion, and involvement of one or both bones were not in adults. J Bow: Joint Surg Am 1992;74A:1068-1078.
associated with the final outcome. 10. Tarr RR, Garfinkel AI. Sarmiento A. 1be effects of angular and rota-
tiooal deformities of both bones of the foreann. J Bone Joint Surg Am
Shorter time from injury to corrective surgery (less than
12 months) was associated with improved forearm rotation 11. Trousdale RT, Linscheid RL. Operative treatment of malunited frac-
and a lower complication rate. tures of the forearm. J Bone Joint Surg Am 1995;77A:894-902.
12. Tynan MC, S, McMahon PJ, et al. 1be effects of ulnar axial
malalignment on supination and pronation. J Bone Joint Surg Am
2000;82A: 1726-1731.
Operative Treatment of
Chapter 7 Radius and Ulna Diaphyseal
t Rena L. Stewart

DEFINfTION Both the curvature of the radius and the integrity of the
interosseous space and interosseous membrane (10M) must
• A diaphyseal forearm fracture is generally considered to be
be maintained for the forearm "'joint" to function optimally.
a nontmion if healing has not taken place within 6 months.
The diaphyseal portions of the radius and ulna are sur-
• Nontmions are generally classified as hypertrophic or at·
rounded by complex anatomy, including neural and vlLSClllar
rophic, an important distinction in treatment selection.
st:ru.ctumi, that must be considered during any surgical ap-
Hypertrophic nontmions have abundant callus and a rich
proach. Both radius and ulna are covered by muscle proxi-
blood supply and result from inadequate stability of fracture
mally, while the ulna emerges distally to be subcutaneous.
fixation. This type of nonunion is rare in the forearm and
constitutuless than 10% of nonunion cases.' PA1HOGENESIS
Atrophic nonunions are characterized by poor blood sup·
ply and little or no callus formation. • Nonunions of the diaphysis of the forearm are rare and re-
• Nontmion of the forearm diaphysis is rare because of the suc- sult most commonly from incorrect or inadequate treatment.
cess of current tuhniques of plate and screw fixation. Nontmion Inadequate fixation, generally less than six cortices of
ram of only 2% in the radius and 4% in the ulna are reported2 screw fixation proximal and distal to the fractur~ will in-
crease the rate of nonunion.
ANATOMY Ladt of att=tion to critical surgical principles such as cre-
ating compression across the fracture site (either with the
• The forearm consists of the radius and ulna, joined at either
use of an interfragmentary screw or a compression plate)
end by the proximal and distal radioulnar joints (PRUJ and
also leads to nontmion.
DRUJ, respectivdy) (FIG 1).
• The ulna is straight, while the radius has both an apex ra- Nonoperative treatment results in markedly increased rates
dial and apex dorsal curvature. of nonunion and other complications.2 With the exception of
isolatW, minimally displaced ulnar shaft fractures, all adult
• It can help to think of the forearm as a joint rather than a
pair of long bones. diaphyseal forearm fractures .require operative management.
• Comminution increases the risk of nonunion, with 12% of
Pronation and supination are achieved by rotation of the
comminuted, diaphyseal fractures going on to develop
curved radius about the straight ulna. 11
nonunion after treatment with dynamic compression plates.
Fracture characteristics that increase the risk of nonunion
include extensive devascularization and periosteal stripping,
Proximal radiolunar joint bone loss, and infection.
Open, comminuted fractures with bone loss have the
highest rate of nontmion. 7
• Patient comorbidities known to increase rates of nonunion
include diabem. mellitus, steroid use, malnutrition, and renal

Once a nonunion of the forearm is established, it will not go
on to heal spontaneously.
• If significant shortening of either the radius or ulna occurs,
the intricate anatomy of the entire forearm "joint" can be dis-
rupted. Malalignment of the DRUJ secondary to such shorten-
ing can cause pain and lead to loss of motion at the wrist.
• Loss of motion secondary to pain, particularly pronation
and supination, can lead to shortening and fibrosis of the
10M. This can lead to permanent loss of rotational motion in
the forearm.


• Patients with nonunion of the diaphysis of the radius or ulna
FIG 1 • The two bones of the forearm form a functional unit, most commonly present with pain.
with the axis of rotation extending from the radiocapitellar This pain frequently worsens with attempts to use the ex-
joint to the distal radioulnar joint. tremity for lifting or pushing, but may also occur at rest.

65 -

Resisted rotational movements are .frequendy painful. • MRI is rarely used but can allow further evaluation of
such as turning a key in a lock. theiOM.
• It is important to explore whether infection could be the • A technetium-99m bone scan followed by an indium-
cause of the nonunion. Important history includes whether or 111-labeled leukocyte scan may be indicated when suspicion
not the original fracture was open, whether postoperative of an infected nonunion exists.
complications or drainage developed, and whether the patient False-positive and false-negative results occur.
has received antibiotics.
• During the physical examination, the examiner should do DIFFERENTIAL DIAGNOSIS
the following: • Malunion
Palpate the nonunion site for pain. • Infection
Grasp the bone on either side of the nonunion and at- • IOM injury
tempt to flex and extend the nonunion to assess fracture sta- • Painful hardware
bility and healing. Palpable motion and increased pain indi-
Loss of flexion-extension in the elbow may result from
• The goal of treatment is to alleviate pain and restore func-
pain. Loss of pronation and supination indicates deranged
tion to the forearm. This can rarely be accomplished without
forearm anatomy or pain.
surgical intervention.
Loss of flexion or extension at the wrist may indicate pain
• In rare circwnstances (if the patient is a high risk for surgery
or scarring of muscle and tendons or IOM arowtd the
due to comorbiditiea, for example), an external bone stimula-
nonunion. Loss of radioulnar deviation may indicate DRUJ
tor can be used.
abnormality secondary to shortening at the nonunion site.
• A minority of patients develop a stable, fibrous nonunion
IMAGING AND OTIIER DIAGNOSTIC that is painless and allows good function. Nonoperative man-
sTUDms agement can be considered in such patients.
• Plain radiographs are essential for diagnosis. This should in-
clude AP and lateral views of the forearm, elbow, and wrist.
Comparative views of the contralateral foreanu, elbow, • In all nonunions of the forearm, the first considerations are
and wrist are also essential for preoperative planning. the patient's level of pain and function.
Plain radiographs will allow the surgeon to dete.rmine if The surgeon should not elect to operate based on radi-
the nonunion is hypertrophic (FIG 2A) or atrophic (FIG 28). ographic findings alone.
• cr is helpful in identifying synostosis, assessing rotational • All patients with nonunions should undergo a workup to
defo.rmity, and evaluating the size of the gap between bone determine if the cause of the nonunion is infection, particularly
ends at the nonunion site. cr also allows assessment of the after open fractures.
DRUJ and PRUJ. The workup should include careful history of open frac·
The metal suppression cr technique minimizes the bright ture, drainage, or postoperative complications after initial
scatter created by retained hardware. surgery.
Blood should be obtained for a complete blood count,
erythrocyte sedimentation rate, and C-reactive protein.
Nuclear medicine imaging should be performed if the
suspicion of infection is high.
Preoperative Planning
• All imaging studies should be reviewed and pathoanatomy
• Plain radiographs should be reviewed for presence or ab·
sence of callus in order to categorize the nonunion as hyper·
trophic or atrophic.
If a nonunion of the forearm is hypertrophic (which is
rare), it may be treated by simple revision of hardware, cre-
ating compression across the fracture site with either a
compression screw or a compression plate. This is the same
technique that should be used for initial management of
radius or ulna fractures (see Chap. HA-4).
• If any possibility of infection at the nonunion site exists,
A B plans must be made to search for infection when the nonunion
site is opened, and to have an alternative treatment plan if in·
FIG 2 • A. Radiograph showing an infected, hypertrophic
nonunion. The abundant callus formation indicates a fection is encowttered.
biologically active nonunion. B. Radiograph showing an Preoperative antibiotics may be held wttil cultures are
atrophic nonunion. There is complete absence of callus at the obtained from the nonunion site (ensure the tourniquet is
fracture site. The problem in an atrophic nonunion is lack of not inflated if antibiotics are administered later in the
biologic activity. (Courtesy ofThomas R. Hunt Ill, MD.) case).

Intraoperative ~ulture swabs and tissue for aerobk, anaer- Positioning

obi~, and fungal ~ultures should be obtained from sites • The patient should be positioned supine with the operative
within the nonunion. arm extended on a radiolu~ent arm table.
Patients should be made aware that if severe infection is • A non sterile or sterile tourniquet may be applied, but full a~­
en~ountered, the planned procedure may need to be altered.
~ess to the elbow is ne~ssary.
For example, if frank purulen~e is encountered, the • Because restoration of the radial bow is a criti~al oomponent
nonunion repair may be abandoned in favor of debridement in restoring forearm motion, intraoperative radiographs show-
and irrigation with possible antibioti~ bead pla~ement and ing the entire radius are essential. For this reason, use of the
even external fixation if stability is oompromised. mini C-arm should be avoided in favor of regular fluoros~opy,
• Template the radiographs to ensure selection of proper plate with its mud larger field of view.
size and length. • The selected site for harvest of autograft should also be pre-
DCP, LCDCP, and ~ombination loding plates are all pared and draped.
A minimum of six oorti~es of ~rew purdase proximal Approach
and distal to the nonunion is criti~al. This may require • The approad to either the radius or ulna should generally
plates longer than those available in a standard plating set. be through the original surgi~al incisions.
In osteoporoti~ bone, the use of lo~g plates should be • Approach to the radius is most ~ommonly volar through the
~onsidered. standard Henry approad. Proximal nonunions of the radius
• If bone graft will be required, the type of graft should be de- may be more easily a~essed via a dorsal Thompson approach,
termined preoperatively. While autograft is still considered the parti~ularly in mus~ular individuals.
gold standard, a vast array of bone graft substitutes are now Care should be taken to identify and prote~t the posterior
available. The surgeon's preferen~e and familiarity with vari- interosseous nerve during this approad.
ous bone graft substitutes may guide this doi~e. It is impor- • The ulna is a~essed along the sub~utaneous border in the
tant to determine if a stru~tural graft will be required, as this interval between the flexor ~arpi ulnaris and the extensor ~arpi
may ne~essitate the use of autograft. ulnaris.
• Patients should be counseled regarding the possible need for Care should be taken to identify and prote~t the dorsal
(and risks associated with) various types of autograft, includ- ~utaneous brand of the ulnar nerve distally.
ing the possible need for a tri~orti~al iliac ~st or fibula graft • In all ~ases, preservation of blood supply is key to healing of
if signifi~ant bone loss is en~ountered. a nonunion. Therefore, periosteal stripping should be kept to
A vascularized fibula graft may be used to fill large de- a minimum and the use of cautery should be restricted to ves-
fects, especially those associated with inf~tion. 1•4•6• 12 sel ~oagulation.
• A ~omplete examination of range of motion of the elbow
and wrist, including pronation and supination, should be per-
formed under anesthesia.


Preparation of the Nonunion • Open the sclerotic bone ends using sequentially larger
diameter drills.
• Determine the correct length of the radius or ulna by
• Pass these drills proximally and distally as far as possi-
measuring the corresponding contralateral bone.
ble to open the medullary canals (I'EOI FIG 1B).
• Expose the nonunion site and search for evidence of
• Restrict elevation of muscle and periosteum to only what
infection. If found, send specimens for Gram stain and
is needed to thoroughly debride the nonunion and to
culture and abort the planned procedure. Perform a
realign the bone.
two-stage reconstruction.
• Realign the bone and restore length by manipulating
• Thoroughly d~bride all necrotic and infected bone
fragments with bone-holding forceps.
and soft tissue. Remove all hardware.
• Use of a small skeletal distractor, small external
• Place antibiotic-loaded PMMA beads in the gap.
fixator, or lamina spreader aids in restoration of
• Begin a multiweek course of antibiotics before pro-
length. 10
ceeding with definitive nonunion repair.
• Measure the length of the residual bone defect directly
• If infection is considered unlikely, after removal of all
and, taking into consideration the preoperative plan, de-
hardware, thoroughly debride the nonunion site of all
termine the appropriate bone graft to use.
necrotic and inflammatory tissue, synovial membranes,
and sclerotic or avascular bone (I'EOI FIG 1A) .
• Tools such as curved curettes, small rongeurs, and a Compression Plating Without
small high-speed burr (with copious irrigation to pre- Bone Graft
vent thermal injury to the bone) are helpful. • In rare cases with minimal or no bone loss at the
• Flatten the bone ends to allow for excellent frag- nonunion site, the bone may be plated in situ without
ment-to-fragment contact with compression. causing shortening. Because the bone remains at normal

'IECH RG 1 • A. Complete d~bridement of the

nonunion site is the essential first step. Any fibrous or
necrotic material must be removed and the bone ends
delivered. B. Medullary canals are opened using in-
I creasing-diameter drill bits to allow vascular ingrowth.

length, the relationship of the radius and ulna at both • The graft should be slightly larger than that required
the DRUJ and the PRUJ is not disrupted and rotation will based on preoperative planning.
be pre5erved. • Precisely contour the graft to fit snugly into the defect.
• This technique may also be used if there is nonunion Square the ends of the graft to match the ends of the
of both the radius and the ulna. Both bones may then bone fragments.5
be shortened a symmetrical distance. • Alternatively, cut both the bone ends of the radius or
• After bone preparation as detailed above, anatomically ulna and of the bone block chamfered, or on the bias,
align the bone ends and precisely apply a compression to increase the area of bony contact.3 This also allows
plate using the same technique employed for acute fore- the graft to be wedged securely in place.
arm fractures. • Insert the graft before plate fixation and fill any residual
• Ensure that compression of the bone ends is achieved. gaps with cancellous bone after plate application.
• If a small bone gap exists after compression, the other
forearm bone may then be shortened to restore the
length relationship.
• Because this approach involves surgery on a normal
bone, this strategy should be used with caution.

Cancellous Bone Grafting

• cancellous bone grafting is generally used for small de-
fects up to 3 em that can be effectively stabilized with a
• Gaps of up to 6 em have been successfully treated
using cancellous bone for grafting.9
• Firmly pad: the cancellous autograft into the residual
nonunion defect after the plate is applied.
• Ensure the graft does not escape from the nonunion site
and come to lie on the 10M ('IECH FIG 2).

Strudural Corticocancellous
Autograft Bone Grafting
• Structural autograft harvested from the anterior or por
terior iliac crest is used for larger defects.
• Expose the superior crest and define the inner and outer
tables. 1ECH RG Z • The nonunion gap is distracted if necessary to
• Utilize a water-cooled sagittal saw and osteotomes to recreate the normal anatomic bone length. A 3.5-mm plate
harvest a tricortical block of bone from the iliac crest. with a minimum of three screws proximal and distal should be
Additionally, harvest cancellous bone to fill defects that used. Cancellous bone graft is inserted and packed in the
may present. nonunion gap.

Nonvascularized Structural Fibula • Tibial allograft is recommended due to its suitable

thickness and mechanical characteristics, which pro-
Autograft With Cortical Allograft
vide excellent screw purchase.8
Bone Grafting
• An appropriate-length segmental graft is harvested from
• Place the cortical allograft along the outer cortex of the
bone, opposite the plate, spanning beyond the length of
the fibula and placed into the defect. the fibula allograft.
• The fibula is approached laterally, via the intramuscular
plane between the peroneal muscles and the soleus.
• Insert the remainder of the screws so that they pass
through the plate and then the patient's bone and
• A cuff of muscle 2 to 3 mm in thickness should be left to finally into the cortical allograft on the opposite side
protect the periosteum. (IEat RG3).
• The 10M is incised longitudinally. taking care to avoid
the posterior neurovascular bundle.
• The fibula is osteotomized proximally and distally to cre-
ate an appropriate-length graft.
• Complications of fibular harvest are rare but indude
transient motor weakness. peroneal nerve palsy, and
flexor hallucis longus (FHL) contracture.
• A minimum of 6 em of the distal fibula must be
retained to avoid adversely affecting the distal
tibiofibular syndesmosis and ankle joint function.
• Insert the fibula graft into the defect and then apply the
plate as described below, first placing the two screws just
proximal and just distal to the nonunion to gain initial
• Select a cortical allograft several centimeters longer than
the defect.

'IEat FIG 3 • Combined intercalary autograft and allograft strut

technique described by Moroni et al.8 After dtibridement of the
nonunion site, an intercalary graft of appropriate length is harvested ; Allograft ) \/
from the patient's fibula and placed in the gap. A cortical allograft is cortical strut \,::-· \,_·
placed opposite to the plate, and screws are placed passing though
the plate, the patient's radius or ulna, and finally the allograft strut. A B


• Select a 3.5-mm (small fragment) compression plate of
adequate length to ensure a minimum of three or four
screws (six to eight cortices} on either side of the
• Always err on the side of a longer plate.
• Thinner locking plates may be considered when struc-
tural fibular autografts are combined with cortical al-
lograft struts.
• Fix the plate to the bone in compression (ensuring that
proper length is maintained) with one screw proximal and
one screw distal to the nonunion. then use full-length flu-
oroscopic views or radiographs of the forearm to ensure
restoration of length, bow, and joint alignment.
• Compare with the contralateral forearm.
• Insert the remaining screws•
• Ideally, screws are not placed into the graft itself and
the graft is stabilized by the compression created by
the plate ('IECH FIG 4).
• aose the wound routinely and apply an above-elbow or
'IEat FIG 4 • Modified Nicoll technique with tricortical iliac crest
sugartong splint.
compressed as the plate is applied.


Indications • Careful evaluation of the patient's pain and functional limitations must be done before surgical
management is planned.
Radiographs • Differentiation should be made between hypertrophic and atrophic nonunions, as treatment differs.
• Contralateral radiographs must be used to determine the appropriate length of the forearm bones
and degree of radial bow.
• Anatomic restoration of length and bow is necessary to allow full rotational motion of the forearm.
Diagnosis of infection • A complete preoperative infection workup should be done for all patients with a nonunion.
• A negative preoperative workup does not rule out infection.
• An intraoperative infection workup, including Gram stain and culture, should be performed and an
alternative plan should be available if infection is encountered.
Nonunion site preparation • Dt!bridement of all necrotic, sclerotic, and avascular tissue from the nonunion site is essential.
• Opening the sclerotic bone ends and gentle reaming of the medullary canals promotes ingrowth of
medullary blood vessels.
• Periosteal stripping and cautery must be minimized to preserve periosteal blood supply.
Graft selection • Defects up to 3 em are successfully managed with cancellous autograft and appropriate fixation.
• Bone graft substitutes may offer alternatives to autograft but no comparative studies exist at this time.
Compression of structural • Compression must be created across all structural grafts.

POSTOPERATIVE CARE • Recurrent nonunion and hardware failure

• Loss of motion
• The longer motion is delayed after surgery, the greater the
• Synostosis
dan~ the patient will devdop stiffness. Therefore, early a~tive
• Pain or other complications at the autograft harvest site
range of motion (ROM) should be initiated at the first postop-
erative visit, ex~ept in ~ases with more tenuous fiXation.
Use of the arm for a~tivities of daily living is en~ouraged. REFERENCES
• If the patient has diffkulty in acllieving satisfa~tory ROM 1. Adani R, Ddcroix L, hw.ocenti M, ct al. R.c:construction of large post-
traumatic skeletal defects of the forearm by vascularized free fibular
with a~tive, a~tive-assisted, and gentle passive ROM, static
graft. Microsurgery 2004;24:423-429.
progressive splints may be used. 2. Chapman MW, Gordon JE, Zissimos AG. Compression-plate fixa-
Having the patient sleep in a static extension splint may tion of acute fractures of the diaphyses of the radius and ulna. J Bone
significantly improve elbow extension. Joint Surg Am 1989;71A:159-169.
• Heavy lifting, pushing, and weight bearing are ddayed 3. Davey PA, Simonis RB. Modification of the NicoU bone-grafting
until radiographic evidence of healing is present, often 3 to technique for nonunion of the radius and/or ulna. J Bone Joint Surg
Br 2002;84B:30-33.
6 months after the index procedure.
4. Dell PC, Sheppard JE. Vascularized bone grafts in the treattw:nt of in-
OUTCOMES fected forearm nonunion. J Hand Surg Am 1984;9A:653~58.
5. Grace TG, Eversman WW. The management of segmental bone loss
• When precise surgi~al tecllniques are used, sud as ~eating associated with forearm fractures. J Bone Joint Surg Am 1980;62A:
stable compression across structural grafts, high rates of union 1150-1155.
are expe~ted. 6. Jupiter JB, Gerhard HJ, Guerrero J, ct al. Treatment of segmental
Rates of healing from 95% to 100% are reported for all defects of the radius with use of the vascularized osteoseptocuta-
neous fibular autogenous grafr. J Bone Joint Surg Am 1997;79A:
of the methods described in this dapter.3 •8 ,9
• Failure of union is related to recurrence of previous infec- 7. Moed BR, KeUam JF, Foster JR, ct al. Immediate internal fixation of
tion in nearly all cases. The prognosis for infected nonunions open fractures of the diaphysis of the forearm. J Bone Joint Surg Am
should be guarded. 1986;68A:1008-1017.
• Patient satisfaction does not correlate directly with bony 8. Moroni AG, Rollo G, Guzzardella M, et al. Surgical treatment of iso-
healing. In multiple studies only two thirds of patients lated forearm non-union with segmental bone loss. Injury 1997;28:
achieved good or excdlent results.3 •5 •8 •9 497-504.
9. Ring D, Allende C, Jafarnia K, eta!. Ununited diaphyseal forearm
• Unsatisfactory results are assodated with poor postopera- fractures with segmental defects: plate fixation and autogenous
tive motion in the majority of cases. cancellous bone-grafting. J Bone Joint Surg Am 2004;86A:
• Other injuries to the upper extremity (~ommon in high- 2440-2445.
energy trauma associated with nonunions) contributed to 10. Ring D, Jupiter JB, Gulotta L. Atrophic nonunions of the proximal
unsatisfa~tory overall fun~tion in a minority of patients.9 •10 ulna. Clin Orthop Relat Res 2003;409:268-274.
• Because nonunion of the forearm diaphysis is a rare condi- 11. Ring D, Rhim R, Carpenter C, ct al. Comminuted diaphyseal frac-
tures of the radius and ulna: does bone graftiDg affect nonunion rate?
tion, no comparative studies of treatment methods exist, in-
J Trauma 2005;59:436-440.
cluding the use of bone graft substitutes. 12. Safoury Y. Free vascularized fibula for the treatment of traumatic
bone defects and nonunions of the forearm bones. J Hand Surg Br
COMPLICATIONS 2005;30B:67-72.
• Infection
• Graft displacement
K-Wire Fixation of Distal
Chapter 8 Radius Fractures With and
Without External Fixation
t Christopher Doumas and David J. Bozentka

DEFINfi10N • The distal radial sensory nerve branches lie superficial to the
distal radius and should be protected during dissection and pin
• Distal radius fractures occur at the distal end of the bone
originating in the metaphyseal region and often extending t~
• The radial sensory nerve emerges between the brachioradi-
the radiocarpal and distal radioulnar joints.
alis and the extensor carpi radialis longus (ECRL) muscle
• Distal radius fractures can be classified as stable or
bellies (FIG 1 ).
unstable and extra- or intra-articular to assist in treatment
• The terminal branches of the lateral antebrachial cutaneous
nerve lie superficial to the forearm fascia at the radial wrist.
• Fractures may angulate dorsal or volar and may have signif-
• There is a bare spot of bone between the first and second
icant comminution, depending on the energy of the injury and
dorsal compartments in the region of the radial styloid.
the quality of the bone.
• The brachioradialis tendon inserts onto the radial styloid
• Percutaneous pins or K-wires, typically 0.062- or 0.045·
adjacent to the first dorsal compartment.
inch, can be used for unstable intra-articular or extra-articular
• The extensor carpi radialis longus and the extensor carpi ra-
fractures with mild comminution and no osteoporosis. dialis brevis lie dorsal to the brachioradialis in the second dor-
• Percutaneous pins can aid reduction and stabilize the frag-
sal compartment.
ments in a minimally invasive manner.
• Lister's tubercle is dorsal, with the extensor pollicis longus
• Percutaneous pins can support the subchondral area of the
(FPL) tendon on its ulnar side, in the third dorsal compartment.
distal radius and maintain the articular reduction in highly
• The extensor digitorum communis tendons lie over the dorsal
comminuted fractures, which is useful in combined fixation
ulnar half of the distal radius in the fourth dorsal compartment.
• The extensor digiti minimi lies over the distal radioulnar
• Smooth percutaneous pins may also be placed across the
joint (DRUJ) in the fifth dorsal compartment.
physis to maintain a reduction in children without causing a
growth arrest.
• Highly comminuted fractures are more difficult to fix rigidly
and often require internal and external fixation to maintain • Distal radius fractures are the most common fractures of the
alignment during healing. upper extremity in adults, representing about 20% of all frac-
• External fixators can be hinged or static, and may or may tures seen in the emergency room.
not bridge the wrist joint. • Mechanism of injury typically is a fall on an outstretched
hand with axial loading. but other common histories include
ANATOMY motor vehicle accidents or pathologic fractures.
• The distal radius consists of three articular surfaces: the • Higher-energy injuries cause increased coouninution, angu-
scaphoid fossa, the lunate fossa, and the sigmoid notch. lation, and displacement.
• Ligamentotaxis aids in the reduction of intra-articular and • Osteoporosis, tumors, and metabolic bone diseases are risk
comminuted fractures. factors for sustaining pathologic distal radius fractures.
Volar ligamentous attachments include the radioscapho- • In children, fractures typically occur along the physis due to
capitate, long radioluoate, and short radioluoate ligaments. its relative weakness compared to the surrounding ligaments.
Dorsal ligamentous attachments include the dorsal inter-
carpal and radiocarpal ligaments. NATURAL HISTORY
• Dorsal and radial to the second metacarpal lie the first dor· • Distal radius fractures needing no reduction and those that
sal interosseous muscle and the terminal branches of the radial are stable after reduction typically recover functional range of
sensory nerve. motion with minimallong-~rm sequelae.

Extensor pollicis

Abductor pollicis
FIG t • Anatomy surrounding the radial
sensory nerve branch in the forearm.

71 -

• Thr~ parameters that aff&:t outcome include articular con-

gruity, angulation, and shortening.16,20
1 to 2 mm of articular surface incongruity of the distal ra-
dius can lead to degenerative changes, pain, and stiffness.
Dorsal angulation can lead to d&:reased range of motion
and increased load tranafer to the ulna.
Radial shortening can lead to d&:reased range of motion,
pain, and ulnar impaction of the carpus.


• The history of a fall on an outstretched hand is the most com-
mon presentation for a patient with a distal radius fracture.
• Motor vehicle or motorcycle accidents and osteoporosis ac-
count for most comminuted fractures.
• It may be clinically indicated to implement a workup for
• Pain, tenderness, swelling, crepitus, deformity, ecchymosis,
and d&:reased range of motion at the wrist are typical symp-
toms and warrant radiographic evaluation.
• Physical examination should include the following:
Inspection: Evaluate the integrity of the skin, cascade of the
digits, direction of displacement, and presence of any swelling. A B
Identify points of maximal tenderness to differentiate be-
tween distal radius injuries and carpal or ligamentous injuries. FIG 2 • A. Lateral radiograph of the wrist demonstrating volar
tilt (b/aclc lines). B. PA radiograph demonstrating radial incli·
Touch or pres& specific areas of the wrist and hand to dif- nation (black lines}, ulnar variance (red bracket), and radial
ferentiate distal intra-articular, DRUJ, and carpal injuries. height (white bracket).
Two-point discrimination: Higher than nonnal (5 rwn)
results in the form of progressive neurologic deficit may sig-
nify an acute carpal tunnel syndrome or ulnar neuropathy.
Passive finger stretch test to assist with diagnosis of com- along the radial styloid to the ulnar articular margin. The
partment syndrome. normal angle is 22 degrees.
EPL tendon function should be evaluated. Ulnar variance, also measured on the PA view (see Fig 2B),
EPL assessment: Assess the resting position of the thumb is the distance between the radial and ulnar articular surfaces.
interphalangeal joint and the patient's ability to lift the Ulnar variance is compared to the contralateral side.
thumb off of a flat surface to determine the continuity of the • Traction radiographs help assess intra-articular involve·
EPI..tendon. ment, intercarpal ligamentous injury, and potential fracture re·
Palpation of forearm and elbow to assess for concomitant duction through ligamentotaxis.
injury proximally. • Cf scans are useful in fully elucidating the anatomy of the
The DRUJ must be assessed for displacement. fracture, including impaction, comminution, and size of the
The bony anatomy must be carefully evaluated to avoid fragments.
missing minimally displaced fractures, which may displace cr scans often significantly altt!r the original treatment
without treatment.
Skin should be assessed to avoid missing an open fracture. • MRI is rarely performed acutely but can diagnose concomi·
Swelling should be monitored to allow for early diagnosis taut ligamentous injuries, triangular fibrocartilage complex in·
of compartment syndrome. juries, and occult carpal fractures.
Sensory examination should be monitored for progressive
changes, which may represent acute carpal tunnel syndrome. DIFFERENTIAL DIAGNOSIS
• Bony contusion
IMAGING AND OTHER DIAGNOSTIC • Radiocarpal dislocation
sTUDms • Scaphoid or other carpal fracture
• Radiographic evaluation should include posteroanterior • Perilunate or lunate fracture dislocation
(PA), lateral, and oblique views to assess displacement, angu- • Distal ulna fracture
lation, comminution, and intra-articular involvement, and • Wrist ligament or triangular fibrocartilage complex injury
allow for radiologic measurements.14•17 • DRUJ injury
Lateral articular (volar) tilt is the angle between the radial
shaft and a tangential line parallel to the articular margin as NONOPERATIVE MANAGEMENT
seen on the lateral view (FIG 2A). The normal angle is • Conservative treatment consists of splinting or casting for
11 degrees. stable fracture patterns using a thr~·point mold.
Radial inclination, measured on the PA view (FIG 28), is • Fractures amenable to nonoperative treatment include frac.
the angle between a line perpendicular to the shaft of the tures that are stable after reduction with minimal metaphyseal
radius at the ulnar articular margin and the tangential line comminution, shortening, angulation, and displacement.

Evaluation for secondary displacement weekly for 2 to

3 weeks is critical as the swelling subsides.
• Unstable patterns will displace if not surgically stabilized.
There is little role for nonoperative treatment in highly
comminuted fractures.
• The physiologic age, medical comorbidities, and functional
level of the patient should be considered in detennining the
need for surgical treatment.
• Early range of motion of the nonimmobilized joints is essen-
tial in the nonoperative treatment of all fractures near the
wrist to prevent contracture.
The cast or splint must not extend past the metacar-
pophalangeal joints so as to allow digital motion.
FIG 3 • Positioning of patient supine on the hand table with
SURGICAL MANAGEMENT tourniquet in place.
• Surgical treatments are indicated to prevent malunion and
improve pain control, function, and range of motion. • A tourniquet is applied near the axilla with the splint still in
• Surgery is reserved for Wl.Stable fractures, including dis- place (FIG 3 ).
placed, intra-articular, comminuted, or severely angulated in- • Fluoroscopy should be used for reduction confirmation and
juries and fractures that displace following attempted closed fixation throughout the procedure.
management. • There must be enough range of motion of the shoulder and
• Percutaneous pinning can assist in obtaining and maintain- elbow to allow standard AP, lateral, and oblique images.
ing reduction of displaced fractures with limited comminution
in a minimally invasive manner. Approach
• External fixators maintain radius length but cannot always • Various approaches can be used in the application of exter-
control angulation and displacement; therefore, supplementa- nal fixators and the insertion of percutaneous pins.
tion with percutaneous pins is typically performed.2 • Distal external fixator half-pins may be placed dired:J.y into
• Conversely, e:x:ternal fixators may augment percutaneous pins the second metacarpal or into other carpal bones (for injuries in-
and plate fixation when extensive comminution is present. cluding the second metacarpal). Wires and half-pins, which are
Supplemental external fixation should be considered for non-bridging fixators, may be placed in the distal radius itself.
fractures with comminution of over 50% of the diameter of • Percutaneous pins can be inserted through the radial styloid
the radius on a lateral view. between the first and second dorsal compartments, through
• External fixation may be used as a neutralization device, Lister's tubercle, through the interval between the fourth and
because the distraction forces decrease soon after fracture fifth dorsal compartments, and across the DRUJ (FIG 4 ).
reduction. Caution is taken to avoid skewering tendons and nerves
• External fixators also are useful for "damage control or- and to avoid penetrating the articular surface.
thopaedics" to temporarily stabilize wrist fractures, esp&:ially
for complex, combined, open injuries. Compartment 5
• For nonbridging external fixation, there must be at least
Compartment 4 Compartment 6
1 em of volar cortex intact and adequate fragment sizes to
allow proper pin placement.
• A relative contraindication to pin fixation with or without
external fixation is a volar shear injury, which should be re-
duced and stabilized using a volar plate and screws.

Preoperative Planning
• All radiographs should be reviewed before surgery and
Compartment 3
brought into the operating room..
• Analysis of the pattern and presumed stability of the frac-
ture fragments determines whether percutaneous fixation, Compartmem 2
with or without external fixation, is suitable.
• For intra-articular fractures, the sp~ific fragments to be re·
duced and fixed must be identified preoperatively to avoid in·
complete reduction of the joint surface.
• The surgeon must be prepared to change his or her manage-
ment d~ision intraoperatively if the fracture behavior is differ-
ent than anticipated. A variety of fixation devices should be
available in the operating room.

• The patient is positioned supine on the operating table with
a radiolucent ann board. FIG 4 • Areas forK-wire insertion at the distal radius.
• aosed reduction should be performed before fixation
using distraction and palmar translation of the distal ra-
dius fragment and carpus. 1
• Use of a padded bump or towel roll will aid in the reduc-
tion (IEat FIG 1).
• Overdistraction will cause increased dorsal angulation
due to the intact short, stout volar ligaments.1
• Excessive palmar flexion of the wrist can restore volar ti It
but leads to an increased incidence of stiffness and
carpal tunnel syndrome.?
• Overdistraction can be assessed by measuring the carpal
height index, measuring the radioscaphoid and midcarpal
joint spaces, checking full finger flexion into the palm, or TECH FIG 1 • Closed reduction over a towel bump using trac-
evaluating index finger extrinsic extensor tightness.• tion and palmar translation.


• Closed reduction is obtained using a bump, and the re- • A stab incision is made radially, and a 0.062-inch
duction is confirmed using fluoroscopy. pin is manually inserted into the fracture site, taking care
• This technique should be employed in patients younger to protect the sensory nerve branches and the first dor-
than 55 years of age with minimal comminution. It should sal compartment tendons (IECH FIG 2A).
not be used in osteoporotic. elderly patients or those • The pin is angled distal, levering the bone back into
with comminution secondary to a higher loss of reduc· its normal position and restoring the radial inclina-
tion. Extemal fixation should be used to supplement pin· tion (IECH FIG 2B) . The pin is advanced through the
ning in these populations.21 far cortex using power, acting as a buttress to prevent
loss of radial inclination (IECH FIG 2C).


1Eat FIG 2 • A. An incision is made over the radial styloid and a K-wire is manually inserted into the fracture site. B. The wire
is levered distally to correct the radial inclination. C. The wire is advanced proximally, using power, into cortical bone. D. An
incision is made over Lister's tubercle, and a wire is inserted into the fracture site. E,F. The wire is levered distally to correct
the dorsal angulation and advanced proximally using power into cortical bone.

• A second stab incision is placed dorsally, and a second pin ceeding into the ulnar cortex of the radius proximal to
is manually inserted into the fracture (IEat FIG 2D). the fracture line.
• The pin is angled distal, levering the bone back into • The pins are buried and cut just below the skin, and the
it$ normal position and restoring the volar tilt (IEat skin is sutured.
FIG 2E). The pin is advanced through the volar cortex • Alternatively, the pins may be bent using two needle
using power, acting as a buttress to prevent loss of drivers and left outside the skin.
volar tilt (IEat FIG 2F). • The pins are then cut and covered with pin caps or antibi-
• Using the modified technique, a third pin is placed retro- otic gauze.
grade using power, starting at the radial styloid and pro- • A sterile dressing is applied, followed by a splint.


• aosed reduction is obtained using a bump, and the re- • One or two K-wires are placed retrograde from the dor-
duction is confirmed using fluoroscopy (IEat RG 3A,B). sal ulnar corner of the distal radius across the reduced
• A small incision is placed over the bare spot on the radial fracture, engaging the opposite cortex in a divergent
styloid between the first and second dorsal compart- fashion (IEat FIG 3F-H).
ments (IEat RG 3 C). • The pins are cut just beneath the skin, which is closed
• Two 0.062-inch smooth K-wires are placed retrograde with a 5-Q nylon suture.
from the radial styloid across the reduced fracture, e~ • Alternatively, the pins are bent and cut and left outside
gaging the opposite cortex in a divergent fashion (IEat the skin (IECH FIG 31).
FIG 3D.E). • A dressing and splint are then applied.
• A small incision is placed over the interval between the
fourth and fifth dorsal compartments.


1Eat FIG 3 • A,B. PA and lateral views demonstrating reduction of distal radius fracture. C. The incision is made
over the radial styloid. D. A pin is inserted retrograde into the radial styloid. E. PA radiograph demonstrating the
course of the radial styloid wire. F. Two radial styloid wires and two dorsoulnar wires are in place. (continued)
75 -

1Eat FIG 3 • (continued) G. PA view showing fixation and the path of the wires. H. Lateral view showing fixa·
tion and path of wires. I. Pins are bent, cut, and covered above the skin.


Distal Pin Placement • The index metacarpophalangeal joint is flexed to pro-
• A3-cm incision is made over the dorsal index metacarpal, tect the sagittal band and first dorsal interosseous
exposing the proximal two thirds. aponeurosis.
• The distal sensory nerve branches are retracted, and the • The metacarpal drill guide is placed on the radial base of
first dorsal interosseous muscle is elevated from the the index metacarpal at the flare of the metaphysis.
metacarpal to identify the insertion of the ECRL (1Eat Partially threaded 3-to4-mm pins are used, with or with-
FIG4A}. out predrilling.


TEat FIG 4 • A. An incision is made over the second

metacarpal base, with reflection of the first dorsal in-
terosseous muscle and radial sensory nerve terminal
branches. (The thumb is at the top of the photograph.)
B. Diagram showing placement of fixator pins in the shaft of
the index and the base of the index and long metacarpals.
C. Parallel placement of two metacarpal pins.

• A long threaded pin is placed through the index and

long metacarpal bases, obtaining three cortices of
• The double drill guide is placed onto the diaphysis of the
radius between the brachioradialis and the radial wrist
fixation. extensors or between the ECRL and ECRB (IECH FIG 51).
• care is taken nat to enter the carpometacarpal joint. • Threaded 3- to 4-mm pins are placed, with or without
• The double drill guide is then placed over the first pin, predrilling.
and the distal short threaded pin is placed through both • The fracture should be reduced, and the pins placed
cortices of the index metacarpal shaft (TECH FIG 4B,C). parallel to the metacarpal pins to facilitate alignment
• Fluoroscopy confirms placement and length of the pins. of the fracture.
• The proximal pin should be placed bicortically, just
Proximal Pin Placement and Frame distal to the tendon of the pronator teres.
Construction • The distal pin is then drilled bicortically through the
• A 4- to 5-<m incision is made over the radial forearm, double drill guide.
proximal to the first dorsal compartment musculature, • Pin placement is confirmed using fluoroscopy•
through skin and subcutaneous tissue, avoiding the lat- • The incisions are closed using nylon suture, ensuring no
eral antebrachial cutaneous nerve branches. tension is on the skin at the pin sites.
• The fascia overlying the interval between the brachiora- • Camps and rods or adjustable fixators may then be ap-
plied to the pins to achieve and maintain final reduction
dialis and the ECRL is divided, and the radial sensory
nerve is identified and retracted (IECH FIG SA). (IECH RG 5C).
• The interval between the E~L and ECRB also may be • Supplementary K-wire fiXation is added before or after
used to avoid the radial sensory branch. external fixation (IECH FIG 5D).

1Eat FIG 5 • A. Incision over the radial forearm demonstrating the radial sensory nerve branch deep to the
fascia. (The hand is to the right.) B. The double drill guide is placed onto the radius. C. Final reduction is main-
tained by the addition of clamps and rods. D. K-wires are used for supplemental fiXation when necessary.


• Fracture reduction can be performed after insertion of the • A longitudinal incision is then made through the retinac-
distal pins.. allowing direct control of the distal fragment. ulum on either side of Lister's tubercle, and the EPL is
• The wrist is placed for a lateral fluoroscopic view, and a protected.
marker is used to determine the level of incision halfway • The first distal pin is drilled using power, parallel to
between the radiocarpal joint and the fracture. A short the radiocarpal joint on the lateral view, halfway
transverse skin incision is made just proximal to the ra- between the fracture and the joint surface (TEat
diocarpal joint. FIG 6A).


1Eat RG 6 • A. Distal pin placement. B. Final reduction with nonbridged

external fixator in place.

• The second distal pin is placed between the second and • The incisions are closed, after which the clamps are ap-
third dorsal compartments, between the radial wrist ex- plied but not tightened.
tensors and the EPL tendon. • Reduction is achieved by manipulation of the distal pins
• This pin should be placed parallel to the first pin in both and clamps.
planes, with the starting point halfway between the ra- • Pushing the pins in the dorsal/volar plane corrects
diocarpal joint and the fracture. dorsal tilt.
• The two proximal radius pins are placed using the tech- • Adjusting the pin clamp can correct radial inclination.
nique described for placement of a bridging external • Reduction is confirmed using fluoroscopy, and the
fixator. clamps are tightened (IEat FIG 68).


Indications • Determine stability.
• Determine comminution and supplement foortion with external or internal fixation as necessary.
Surgical approach • Make skin incisions for pin placement to avoid sensory nerves, tendons, and crossing veins.
• Obtain adequate exposure of the radial sensory branch at forearm and hand to avoid injury.
Hardware placement • Choose pins of appropriate diameter.
• Supplement fixation with pins, using external or internal fixation as necessary.
• Do not leave pins more than 1 to 2 mm out of the cortex. and keep all pins extra-articular.
• If placing the proximal metacarpal pin in metaphyseal bone, ensure that three cortices are penetrated.
• Do not back out conical pins, because fixation will be lost.
• Evaluate the DRUJ after fixation to determine stability.
• Subcutaneous pins are more costly to remove, because that requires a second procedure, but they
have a lower infection rate. Therefore, if foortion is needed for an extended period, bury the pins.
• OVerdistraction of the carpus must be avoided. because it is associated with chronic pai~mediated
syndromes and nonunion.
Postoperative management • Allow for adequate immobilization.
• Encourage early range of motion of the fingers, elbow, and shoulder whenever possible.
• Educate the patient regarding appropriate pin care.
• Begin strengthening only after healing is complete and range of motion is maximized.

POSTOPERATIVE CARE • External fixation devices typically require no additional

• After fixation with percutaneous pins, alone the wrist is im- immobilization, although a volar forearm-based Orthoplast
mobilized in a short-arm splint to allow for swelling but pro- Uohnson &:: Johnson, Langhorne, PA) splint may be used for
vide stabHity. A cast is applied after the swelling goes down. support and patient comfort.
• Isolated radial styloid fractures fixed with pins can be • The splint or cast is continued for 4 to 8 weeks, until heal-
placed in a volar wrist splint. ing occurs and the pins are removed.

• K-wires and half pins should be inspe~ted and deaned regu- • Loss of range of motion
larly using either soap and water or half-strength hydrogen • Posttraumati~ arthritis
peroxide and water. • Weakness in grip or pin~h
• Finger, elbow, and shoulder range of motion are begun • Tenosynovitis and tendon rupture
immediately, and wrist range of motion is begun as the frac- • Malunion or nonunion
ture heals. • Compartment syndrome
• Carpal tunnel syndrome
OUTCOMES • Hardware failure
• A prospective randomized trial comparing percutaneous pin- • Nonunion (associated with overdistraction with an external
ning and casting versus external fiXation with augmentation (eg, fixator)
pins, screws, bone graft) found no differen~e in dinical out- • Complex regional pain syndrome type I (assodated with
~omes for fractures with minimal articular displacement.9 overdistraction with an external fixator)
• In patients over 60 years of age, percutaneous pinning has
been shown to provide only marginal radiographic improve- REFERENCES
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stability was not evaluated. 19 fractures of the distal radius. Acta Orthop Belg 2006;72:138-146.
16. Short WH, Palmer AK, Werner FW, et al. A bionu:chanical study of
distal radial fractures. J Hand Surg Am 1987;12:529-534.
COMPLICATIONS 17. Simic PM, Weiland AJ. Fractures of the distal aspect of the radius:
• Infection (pin tract or deep). Pin tract infections o~cur in changes in treatment over the past two decades. J Bone Joint Surg Am
10% to 30% of patients.8 •9
18. Sommerkamp TG, Seeman M, Silliman J, et al. Dynamic external fix-
• Injury to tendons, vessels, and nerves due to percutaneous ation of unstable fractures of the distal part of the radius. A prospec-
tednique. Stiffness may result if tendons are inadvertently tive, randomized comparison with static extemal fixation. J Bone
skewered, and the radial sensory branch can be injured. Joint Surg Am 1994;76A:1149-1161.

19. Souer S, Ring D, Matschke S, et al. Efrect of an unrepaired fracture 21. Trumble TE, Wagoer W, Hanel DP, et al. Intrafocal (Kapandji)
of the ulnar styloid base on outcome after plate and screw fixation of pinning of distal radius fractures with and without exremal fixation.
a distal radius fracture. J Bone Joint Surg Am 2009;91:830-838. JHand Surg Am 1998;23:381-394.
20. Trumble TE, Schmitt SR, Vedder NB. Factors affecting functional 22. Westphal T, Piarek S, Schubert S, ct al. Outcome afrer surgery of dis-
ouocome of displaced intra-articular distal radius fractures. J Hand tal radius fractures: no differences between external fixation and
Surg Am 1994;19:325-340. ORIF. Arch Orthop Trauma Surg 2005;125:507-514.
- Arthroscopic Reduction and
Chapter 9 Fixation of Distal Radius and
Ulnar Styloid Fractures
William B. Geissler

DEFINITION Type I fractures are bending fractures of the metaphysis in

which one cortex fails to tensile stress and the opposite one
• A bimodal age distribution exists for patients with distal ra-
undergoes a certain degree of comminution (eg, extra-artic-
dius fractures (ie, young adults vs elderly persons), and they
ular Smith or Colles' fractures).
frequently have a different mechanism of injury.
Type IT fractures are shearing fractures of the joint surface
• Patients 65 years of age or older have an annual incidence
(eg, radial styloid fractures, Barton's fracture).
of 8 to 10 fractures of the distal radius per 1000 person-years.
Type m fractures are compression fractures of the
The incidence is seven times higher in women than in
joint surface with impaction of the subcondral and meta·
physeal cancellous bone (ie, intra-articular comminuted
Sixteen percent of white women and 23% of white men
will sustain a fracture of the distal radius after the age of
Type IV fractures are avulsion fractures of ligamen-
SO years.
tous attachments, including radial styloid and ulnar styloid
• Fractures of the distal radius are one of the most common
fractures, and are associated with radiocarpal fracture·
skeletal injuries treated by orthopaedic surgeons.
• These injuries account for one-sixth of all fractures that are
Type V fractures are high-energy injuries that involve a
evaluated in the Emergency Department.
combination of bending, compression, shearing, and avul-
• Displaced intra-articular fractures of the distal radius are a
sion mechanisms or bone loss.
unique subset of radius fractures. 18
These fractures are a high-energy injury.
• Several studies have shown that a high incidence of associ-
ated soft tissue injuries is seen with displaced intra-articular
This high-energy injury results in comminuted fracture distal radius fractures.9,tt-13,17,t9,.20
Arthroscopic studies demonstrate a high incidence of in-
These fractures are less amenable to traditional closed
jury to the triangular fibrocartilage complex, followed by
manipulation and casting.
the scapholunate interosseous ligament, and then the
• The prognosis for these fractures depends on the amount of
lunotriquetral interosseous ligament (which is the least
residual radius shortening, both radiocarpal and radioulnar
articular congruity, and associated soft tissue injuries.22.U
A spectrum of injury occurs to the interosseous ligament
ANATOMY in which it attenuates and eventually tears and the degree of
rotation between the carpal bones increases.
• The distal radius serves as a plateau to support the carpus. Geissler et al defined an arthroscopic classification of
• The distal radius has three concave articular surfaces: the interosseous ligament tears that helps define the degree of
scaphoid fossa, the lunate fossa, and the sigmoid notch.
ligament injury and secondary instability as well as
• The distal articular surface of the radius has a radial in-
proposes treatment (Table 1; see also Chap. HA41).
clination averaging 22 degrees and palmar tilt averaging
11 degrees.
• Radial-based volar and dorsal ligaments arise from the dis- NATURAL HISTORY
tal radius to support the wrist. • Intra-articular fractures of the distal radius have two
• The sigmoid notch of the distal radius articulates with the pathologies: the associated global injury to the soft tissues and
ulnar head about which it rotates. the injury to the bone itself.
The distal radioulnar joint (DRUJ) is primarily stabilized • The natural history for an intra-articular fracture of the dis-
by the triangular fibrocartilage complex (TFCC). tal radius depends on restoration of anatomy as well as detec·
• The sigmoid notch angles distally and medially at an aver- tion and management of any associated soft tissue injuries.1•4
age of 22 degrees. • Knirk and Jupiter13 documented the importance of articular
restoration over extra-articular orientation in predicting out-
PATHOGENESIS comes for fractures of the distal radius.
• The biomechanical characteristics of each fracture type de- They showed solid evidence that the largest tolerable ar-
pend on the mechanism of injury. ticular step·off is 2 mm.
• Fernandez and Geissler4 developed a classification based on They demonstrate that the better the restoration of the ar-
the mechanism of injury. They noted that the associated liga- ticular surface, the better the outcome.
mentous lesions, subluxations, and associated carpal fractures • A loss in radius length of 2.5 mm will shift the normal load
are related ~dy to the degree of energy absorbed by the dis- transmitted across the ulna from 20% to 42%, which may
tal radius. lead to various stages of ulnar impaction syndrome.


Table 1 Geissler Arthroscopic Classification of Carpal Instability

Grade Definition Arthroscopic Findings Management

I Atll!nuationlhemorrhage of There is a loss of the normal concave appearance between Immobilization
interosseous ligament as seen the carpal bones, and the interosseous ligament attenuates
from the radiocarpal joint. and becomes convex as seen from the radiocarpal space. In
No incongruency of carpal midcarpal space, the interval between the carpal bones will
alignment in the midcarpal still be tight and congruent, with no step-off.
II Attenuation/hemorrhage Aslight gap (less than the width of a probe) between the Arthroscopic reduction and
of the interosseous ligament carpal bones may be present The interosseous ligament pinning
as seen from the radiocarpal joint. continues to become attenuated and is convex as seen from
lncongruency/step-off as the radial carpal space. In the midcarpal space, the interval
seen from the midcarpal space. between the involved carpal bones is no longer congruent,
A slight gap between and a step-off is present In scapholunate instability, palmar
the carpal bones may be present flexion of the dorsal lip of the scaphoid will be seen as
compared to the lunate. In lunotriquetral instability,
increased translation between the triquetrum and lunate
will be seen when palpated with a probe.
Ill lncongruency/step-off of carpal The interosseous ligament has started to tear, usually from Arthroscopidopen reduction
alignment is seen in both the volar to dorsal, and a gap is seen between the carpal bones and pinning
radiocarpal and midcarpal spaces. in the radiocarpal space. A probe often is helpful to separate
the involved carpal bones in the radiocarpal space. In the
midcarpal space, a 2-mm probe may be placed between the
carpal bones and twisted.
IV lncongruency/step-off of carpal A2.7-mm arthroscope may be passed through the gap Open reduction and repair
alignment is seen in both the between the carpal bones. The interosseous ligament is
radiocarpal and midcarpal spaces. completely detached between the involved carpal bones. This
Gross instability with manipulation is the • drive-through • sign, when the arthroscope may be
is noted. freely passed from the radiocarpal space through the tear
to the midcarpal space.

• Untreated complete tears of the scapholunate interosseous • Diminished sensibility, pallor, altered capillary refill, in-
ligament, which are highly associated with radial styloid creased tenseness of the soft tissues, and pain out of propor-
fractures, may progress to a wrist with scapholunate ad- tion should raise suspicion for significant soft tissue injury, in-
vanced collapse. cluding compartment syndrome.


• A thorough history should be obtained, including the cir- • Posteroanterior (PA), oblique, and lateral radiographs
cwnstances surrounding the injury as well as any additional are the primary radiographic workup for distal radius
injuries. fractures.
Neurologic basis Contralateral radiographs of the uninvolved extremity are
Cardiac basis useful to compare radial inclination, ulnar variance, and sig-
Patients' levd of independence, dominant hand, status moid notch anatomy.
with assisted devices, work, activity level, and support struc- PA projections are useful to evaluate the radial inclina-
ture should be determined. tion, radius height, presence of ulnar styloid fractures,
• Physical examination, while concentrating on the wrist, widening of the DRUJ, widening of intracarpal spaces, and
should also include the hand, elbow, and shoulder to check for intra-articular involvement (FIG 1A).
concomitant injuries. Standard radiographic parameters of the distal radius
The hand, wrist, arm, and shoulder must be carefully in- include radial inclination of 23 degrees (range 13-30), ra-
spected for open injury so that tetanus and antibiotic pro- dius length of 12 mm (range 8-18 mm), and volar tilt of
phylaxis may be initiated if necessary. 12 degrees (range 1-21 degrees).
Thorough distal sensory and motor function examination Ulnar variance shoulde be measured with the shoulder
should be carried out in an organized manner. in 90 degrees of abduction, the elbow at 90 degrees of
Vascular examination should include palpation of both flexion, and the wrist in neutral pronation-supination.
the radial and ulnar pulses and determination of capillary A lateral projection is used to assess volar and dorsal tilt
refill time. of the distal fragment, disloottion or subluxation of the
Precise palpation is used to defme areas of potential DRUJ or carpus, lunate angulation, and dorsal comminu-
trauma. tion (FIG 1 B).

Knowledge of the mechanisms of injury helps facilitate

manual reduction. Force is applied opposite the force that
caused the fracture.
Gentle traction is necessary to disimpact the fracture frag-
ments, followed by palmar translation of the hand and car-
pus in respect to the radius.
The radius articular surface will rotate around the intact
volar cortical lip to restore volar inclination with palmar
translation. must be taken to avoid trauma to the skin during the
reduction maneuver, particularly in elderly patients where
the skin may be fragile.
• A splint is supplied following the reduction. No consensus
has been established regarding wrist or forearm position, long-
arm versus short-arm immobilization, or splint versus cast.
FIG 1 • A. PA radiographic view showing a minimally displaced Extreme positions of wrist .flexion and ulnar deviation
radial styloid fracture fragment. B. The lateral view shows a
should be avoided.
complete fracture-dislocation of the wrist.
Postreduction radiographs are taken in plaster.
• Depending on stability of the fracture, most patients treated
nonoperatively require weekly visits for the first 3 weeks to
A modified lateral radiograph with the beam angulatiug monitor fracture reduction.
10 to 30 degrees proximally improves visualization of the In patients older than 65 years, one third of initially undis-
articular surface and evaluation of the volar rim of the lu- placed fractures subsequently collapsed to some degree.
nate facet represented by the anterior teardrop. One study of elderly patients with moderately displaced
An additional 30-degree anteroposterior (AP) cephalic fractures of the distal radius found that two thirds of the cor-
projection is useful to evaluate the dorsal ulnar margin of rection obtained by closed manipulation was lost at 5 weeks.
the distal radius. • Patients with minimally displaced or nondisplaced fractures
Oblique radiographs are very helpful, because major of the distal radius treated nonoperatively must be made
fracture fragments may be rotated out of their anatomic aware of possible complications, including rupture of the ex-
planes. tensor pollicis longus tendon. carpal tunnel syndrome, and
• CT evaluation. particularly three-dimensional CT, can fur. compartment syndrome.
ther delineate fragment location, joint compression, and
• MRI evaluation is useful in assessing for associated soft tis-
• Distal radius fractures without extensive metaphyseal com-
sue injuries such as TFCC tears, interosseous ligament injuries,
munition are ideal candidates for arthroscopic-assisted fixa-
and carpal fractures. tion with K-wires or cannulated sc.rews.7•8
• Radiographic signs that demonstrate that the distal radius Radial styloid fractures
fracture is likely unstable and closed reduction would be insuf· Impacted fractures
ficient include15: Die punch fractures
Lateral tilt greater than 20 degrees dorsal
• Three-part T-type fractures and four-part fractures with
Dorsal comminution greater than 50% of the width
metaphyseal comminution are best treated with a combination
Initial fragment displacement greater than 1 em
of volar plate stabHization. Wrist arthroscopy is used as an ad-
Volar translation greater than 2 mm
junct to fine-tune the articular reduction and evaluate for as·
Initial radius shortening more than 5 mm sociated soft tissue lesions.
Intra-articular step-off greater than 2 mm
• Distal radius fractures that may be minimally displaced, and
Associated ulna fracture fractures with strongly suspected associated soft tissue injury,
Severe osteoporosis. also are candidates for arthroscopic-assisted fixation to stabi-
Age greater than 60 years lize the fracture but, more importandy, to evaluate and treat
the acute associated soft tissue injury.
DIFFERENTIAL DIAGNOSIS • Stabilization of associated ulnar styloid fragments is contro-
• Carpal bone fracture versial.13 Wrist arthroscopy provides a rationale as to when to
• Metacarpal or phalangeal fracture stabilize an ulnar styloid fragment.
• DRUJ disruption
• Esse:x-Lopresti lesion Preoperative Planning
• Interosseous ligament tear • All radiographic studies are reviewed.
• Carpal dislocation (perilunate) • Equipment needed for arthroscopic treatment and for open
stabilization is made available.
NONOPERATIVE MANAGEMENT Small joint instrumentation is essential for arthroscopic-
• Displaced fractures of the distal radius are reduced using an assisted fixation of distal radius fractures. The small joint
adequate anesthetic agent. arthroscope is approximately 2.7 mm in diameter, and even
83 -

smaller scopes may be used if desired. In addition. a small • It is difficult to palpate the nonnal extensor tendon land-
joint shaver (3.5 mm or leas) is useful to clear fracture debris marks for traditional wrist arthroscopy in patients who sustain
and hematoma. a fracture of the distal radius because of swelling. 10 However,
• The ideal t:iming for arthroscopic-assisted fixation of distal the bony landmarks usually can still be palpated. These bony
radius fractures is 3 to 10 days following injury. 6 landmarks include the bases of the metacarpals, the dorsal lip
Earlier attempts at .fixation may be complicated by soft of the radius, and the ulnar head.
tissue swelling and troublesome bleeding. obscuring visual- • The 3/4 portal is made in line with the radial border of the
ization. long finger. It is very uae.fu1 to place a no. 18 needle into the
After 10 days, the fracture fragments start to become sticky proposed location of the 3/4 portal before making a skin
and more difficult to percutaneously elevate and reduce. incision.
If the portal is placed too proximal, the arthroscope
Positioning may be placed within the fracture pattern itself. If it is
• Arthroscopic-$sisted fixation of distal radius fractures may be placed too distal, it can injure the articular surface of the
performed with the arm suspended vertically in a traction tower, carpus.
horizontally in a traction tower, or with finger traps applied at- • Once the precise ideal location of the portal is located, the
tached to weights hanging over the edge of the hand table. portal is made by pulling the skin with the sugeon's thumb
Wrist arthroscopy in the horizontal position may make it against the tip of a no. 11 blade. Blwtt dissection is carried
easier to simultaneously monitor the reduction fluoroscopi- down with a hemostat, and the arthroscope, with a blunt tro-
cally and place hardware. However, it does not allow for si- car, is introduced into the dorsal 3/4 portal.
multaneous volar access to the wrist. This technique decreases potential injury to cutaneous
Suspending the wrist in a vertical position with a traction nerves.
tower allows simultaneous access to both the volar and dor- • Thorough irrigation of the joint is necessary to wash out
sal aspects of the wrist. This is particularly useful when fracture hematoma and debris and improve visualization.
wrist arthroscopy is used as an adjunct to volar plate fixa- Inflow may be provided through the arthroscope cannula or
tion of the distal radius fracture. separately through a no. 14 needle into the 6U portal.
• A new traction tower has been designed to allow si- Use of a separate 6U inflow portal is recommended. The
multaneous evaluatation of the intra-articular reduction of the small-joint arthroscopy cannula does not allow as much
distal radius arthroscopically and fluoroscopically (FIG 2A). space between the cannula and the arthroscope, limiting the
The surgeon may stabilize a comminuted fracture of the amount of flow through the cannula.
distal radius with a plate and simultaneously evaluate the Outflow to the wrist is provided through intervenous ex-
articular reduction arthroscopically. tension tubing connected to the arthroscope cannula.
The traction tower allows for traction of the wrist in ei- • The 4/5 working portal is made in line with the mid-axis of
ther the vertical or horizontal planes, depending on the sur- the ring metacarpal. Alternatively, the 6R working portal is
geon's preference (FIG 28). made just radial to the palpable extensor carpi ulnaris tendon.
A no. 18 needle is placed into the joint and should lie just
Approac:h distal to the articular disc.
• The wrist is suspended in a traction tower, and the standard A 415 or 6R portal usually is located just proximal to the
dorsal 3/4 viewing portal, 415 or 6R working portal, and 6U 3/4 portal because of the natural radial slope of the distal
inflow portal are made. radius.

FIG 2 • A. This traction tower (A<:umed, Hillsboro,

OR) uses a suspension bar at the side rather than at
the center of the wrist. This allows easy fluoro-
scopic evaluation of the fracture reduction, with si-
multaneous full access to the volar and dorsal as-
pects of the wrist. B. The tower can be flexed into
a horizontal position for surgeons who prefer to
A B treat distal radius fractures in that position.


• An isolated fracture of the radial styloid is an ideal frac- • Using the previously placed guidewires as joysticks, ma-
ture pattern to manage arthroscopically, especially for the nipulate and anatomically reduce the fracture fragment
surgeon beginning to gain experience in arthroscope- under direct arthroscopic observation.
assisted fucation of distal radius fractures. • A trocar can be inserted through the 314 portal to
• In addition, radial styloid fractures have a high incidence help further guide the reduction of the radial styloid
of associated injury to the scapholunate interosseous li~ fragment ClEat FIG 1A,B).
ament, which is best assessed arthroscopically. • Once the fracture is judged to be absolutely anatomic,
• Insert one or two guidewires from a cannulated screw the guidewires are advanced across the fracture site into
system percutaneously into the radial styloid--not across the radius shaft and evaluated under fluoroscopy (IEat
the fracture site--using a wire driver in oscillation mode. FIG 1C).
• Evaluate the position of the wires under fluoroscopy • In many cases, the fracture reduction may look
to ensure they are centered in the radial styloid anatomic under fluoroscopy, but when viewed
fragment. arthroscopically, the radial styloid fragment is seen to
• Suspend the wrist in a traction tower and establish the be slightly rotated.3
standard arthroscopic portals. • Guidewires alone can be used to stabilize the fracture,
• Insert the scope in the dorsal 3/4 portal and clear the but cannulated screws (with or without heads) are rec-
joint of debris and hematoma. ommended (IEat FIG 1D,E).
• Transfer the arthroscope to the 6R or 415 portal to look • cannulated screws decrease soft tissue irritation and
across the wrist and effectively judge rotation and reduc- potential pin track infection as compared with K-
tion of the radial styloid fragment. wires.

TEat FIG 1 • A. Arthroscopic view of the patient whose radiographs are seen in Figure 1. The arthroscope is in the 6R por-
tal looking across the wrist, and a blunt trochar is in the 3/4 portal. The displaced radial styloid fragment is well visualized.
B. A combination of joysticks inserted into the radial styloid fragment and a trochar inserted into the 3/4 portal allows
anatomic reduction of the displaced radial styloid fragment and radiocarpal joint. C. The radial styloid fragment is anatom-
ically reduced (with no residual rotation) and stabilized. D. PA view demonstrating anatomic reduction to the radial styloid
fragment. Headless cannulated screws are used, if possible, to avoid soft tissue irritation. E. Lateral view showing anatomic
restoration to the radial styloid fragment and restoration of the carpus in line with the radius.
• Three-part fractures that involve a displaced fracture of • Use a bone tenaculum to further diminish the gap be-
the radial styloid and a lunate facet fragment without tween the radial styloid and lunate facet fragments.
metaphyseal communution are ideal for arthroscopic-as- • Place guidewires transversely under the subchondral sur-
sisted reduction (IEat FIG 2A,B). face of the radius from the radial styloid into the
• Reduce and provisionally stabilize the radial anatomically reduced lunate facet fragment.
styloid fragment with guidewires under fluoroscopic • It is important to pronate and supinate the wrist fol-
guidance. lowing placement of the transverse pins to ensure the
• The radial styloid serves as a landmark to which the guidewires have not violated the DRUJ. The concave
depressed lunate facet fragment is reduced. nature of the DRUJ makes radiographic assessment
• Suspend the wrist in the traction tower, establish portals, difficult.
and evacuate the fracture debris and hematoma. • Consider insertion of bone graft to support the reduced
• The depressed lunate facet fragment is best seen with lunate fragment and avoid late settling.
the arthroscope in the 3/4 portal (IEat FIG 2C.D}. • Make a small incision between the fourth and fifth
• Percutaneously place a no. 18 needle directly over the dorsal compartments.
depressed fragment as viewed arthroscopically. • Use cancellous allograft bone dlips or bone substitutes.
• Insert a large K-wire about 2 em proximal to the previ- • If feasible, place headless cannulated screws to stabilize
ously placed no. 18 needle to percutaneously elevate the both the radial styloid and the impacted lunate facet
depressed lunate facet fragment. fragments (IECH FIG 2E~).



'IECH FIG 2 • A. PA view showing a impacted scaphoid facet fracture fragment

with an obvious injury to the scapholunate interosseous ligament. B. Lateral view
showing a dorsal rim fracture fragment. C. The arthroscope is in the 6R portal,
demonstrating the impacted scaphoid facet fracture fragment. This would be
quite difficult to view through an open arthrotomy, but is well visualized arthro-
scopically under bright light and magnified conditions. D. The impacted scaphoid
facet fragment is elevated back to the volar rim, using the rim as a landmark to
judge rotation. E.F. Geissler grade Ill tear involving the scapholunate in-
terosseous ligament as seen through the 3/4 portal (E) and the radial midcarpal

TECH FIG 2 • (continued) G,H. PA and lateral ra-

diographs showing anatomic reduction to the
impacted scaphoid facet fracture. (The tear of
the scapholunate interosseous ligament also was
G acutely repaired.}


• A combination of open surgery, using a volar plate for • Provisionally pin the distal fragments through the
stability, and arthroscopy, as an adjunct to assist the ar- plate.
ticular reduction, is used if metaphyseal comminution is • Manipulate the articular fragments under fluoroscopy to
present (TECH FIG 3). obtain as anatomic a reduction as possible (IECH FIG
• Volar plate stabilization is very stable and allows for 4C,.D).
early range of motion and rehabilitation as compared to
K-wires or headless screws alone.
• Suspend the wrist in the traction tower and reduce the
articular fragments arthroscopically (TECH FIG 4E.F}.
• If articular reduction is not anatomic, remove the pins
Open Redudion and Stabilization and fine-tune the reduction.
• Perform a standard volar approach and do not open the • Once the fracture reduction is thought to be anatomic,
place the distal screws through the plate (IECH FIG 4CH).
radiocarpal joint capsule (IECH RG 4A).
• The radial styloid fragment and the volar ulnar fragment • It is important that the fracture be reduced to the
are reduced to the shaft under direct visualization. The plate. with no gap between the plate and the bone.
radial styloid fragment is provisionally pinned. This can be achieved by flexion of the wrist in the
• Apply a volar distal radius locking plate to stabilize the tower and by insertion of a non-locking screw first,
volar bone fragments (TECH FIG 41). before the insertion of standard locking screws.
• Place a screw in the proximal portion of the plate • Place the remaining proximal and distal screws if the
reduction is anatomic under both fluoroscopy and
first.. to reduce the plate to the shaft.

1ECH FIG 3 • A. The PA radiograph

shows a displaced fracture of the radial
styloid. B. This lateral radiograph shows
metaphyseal comminution associated
with the displaced radial styloid frag-
ment. Because of the metaphyseal com-
minution, it was decided to stabilize the
A I fracture using a volar plate.

TECH FIG 4 • A. A standard volar approach is made, centered over the flexor carpi radialis tendon, and the fracture
site is exposed. B. A volar distal radius locking plate (Acumed, Hillsboro, OR) is applied. The initial screw is placed
through the proximal plate to secure the plate to the shaft. C. The intra-articular reduction is viewed under fluoroscopy
and provisionally pinned. A displaced intra-articular fracture fragment can still be identified. D. The arthroscope is in
the 3/4 portal, showing the volar capsule blocking reduction of the radial styloid fragment. E. Joysticks previously in-
serted into the radial styloid fragment are then used to control and anatomically reduce the radial styloid fragment.
F. The arthroscope is in the 6R portal looking across the wrist. Anatomic reduction of the radial styloid fragment is doc-
umented. G. Once the anatomic restoration of the articular surface is evaluated both arthroscopically and fluoroscop-
ically, the distal screws are placed in the plate. H. Fluoroscopic view showing anatomic restoration to the articular sur-
face of the distal radius. I. The patient had an associated osteochondral fracture of the lunate, not visible on plain ra-
diographs. The displaced fragment is arthroscopically removed.

Reduction and Stabilization of a • The dorsal die punch fragment is best seen with the
arthroscope in the 6R portal.
Dorsal Die Punch Fragment
• It is not possible to see the reduction of a dorsal die
• Establish the volar radial portal between the ra-
dioscaphocapitate ligament and the long radiolunate
punch fragment through the volar approach when sta-
ligment,. as viewed directly through the previous per-
bilized with a plate. Arthroscopy can be helpful in this formed volar approach.16
• Insert the volar plate as previously described and provi-
• Percutaneously elevate and anatomically reduce the dor-
sal die punch fragment as viewed arthroscopically.
sionally fix the device to the radius.
• Frequently, the dorsal fragment may still be slightly
• Once this has been achieved, place the screws into the
plate and observe their path arthroscopically to ensure
proximal in relation to the radial shaft.
adequate stabilization of the dorsal die punch fragment.


• Following anatomic reduction of the distal radius frac- • Place the cannulated headless screw over the guidewire
ture, insert the arthroscope in the dorsal 3/4 portal and and verify fracture reduction with fluoroscopy.
the probe in the 6R portal. Palpate the tension of the ar- • Insert the arthroscope into the 3/4 portal and the probe
ticular disc. into the 6R portal to document restoration of TFCC
• Good tension indicates that the majority of the pe- tension.
ripheral TFCC fibers are intact or still attached to the
proximal ulna.
• A peripheral tear of the articular disc is repaired
arthroscopically when detected.21
• Stabilization of a large ulnar styloid fragment is consi~
ered when the articular disc is lax by palpation and no
peripheral TFCC is identified (IECH FIG 5).
• In this instance, the majority of the fibers of the TFCC
are attached to the displaced ulnar styloid fragment.
• Make a small incision between the extensor carpi ulnaris
and the flexor carpi ulnaris tendons and identify the frac-
ture site.
• Retrieve the distal fragment, which often displaces in a
distal and radial direction.
• Mobilize the styloid fragment using a no. 15 blade, tak-
ing care to protect the TFCC insertion.
• Reduce the fragment anatomically, under direct visual-
ization, and insert a guidewire in a retrograde manner
TECH FIG 5 • In this case, following reduction to the distal ra-
for provisional stability. dius fracture, the articular disc was palpated and found to be
• Stabilize the ulnar styloid fragment using either ate~
sion band technique (with wire and two K-wires) or,
lax but with no peripheral tear. The large ulnar styloid frag-
ment was reduced with a micro Acutrak screw (Acumed,
preferably, using a micro headless cannulated screw. Hillsboro, OR).


Timing of reduction • Arthroscopically assisted reduction of distal radius fractures is most ideal between 3 and 10 days
following injury. Assisted fiXation before 3 days usually is complicated by bleeding that can obscure
visualization. Percutaneous fracture reduction more than 10 days after the injury is exceedingly
difficult and often unsucce!6ful.
Arthroscopic visualization • It is important to take the time to thoroughly irrigate and dC!bride the joint of hematoma and
debris. This especially helps visualization of fragment rotation. Irrigation through a separte 6U
inflow portal is helpful. A Coban wrap (3M, St. Paul, MN) may be wrapped around the forearm to
limit fluid extravasation into the soft tissues.
Instrumentation • Large-joint instrumentation will damage the articular cartilage and is not appropriate. A mobile
traction tower is extremely helpful in arthroscopic-assisted management of distal radius fractures.
Fixation • Do not substitute poor foortion for an arthroscopically assisted procedure. Fixation should be
chosen to frt the personality of the fracture. For example, K-wires should not be used to stabilize a
volar Barton's fracture when volar plate stabilization is the obvious choice. While K-wires are easy
to insert, they hinder rehabilitation and have the potential for pin track infections.

• Cannulated screws are recommended when arthroscopically stabilizing a fracture of the distal ra-
dius without metaphyseal comminution.
• Volar plate fixation is recommended when metaphyseal comminution is present.
• Arthroscopic evaluation of the wrist while the distal screws are being placed offers the advantage of
seeing the screws penetrate into the fracture fragments, thereby ensuring stability. Arthroscopic eval-
uation is helpful in variable-angle volar locking plates to ensure the screws do not violate the joint.
Observation • It is imperative following arthroscopically assisted reduction ofthe distal radius in the radiocarpal
space to evaluate the midcarpal space. The midcarpal space is the most sensitive and ideal location
to evaluate intercarpal stability. In addition, loose bodies from the capitate or hamate occasionally
are seen, particularly in association with lunate die punch fractures. Arthroscopic evaluation also
aids in determining when to fix the ulnar styloid.


• The degree of postoperative immobilization depends on nu- • Failure of fixation
merous fa~tors, including the mode of fra~ture stabilization, • Late settling of the fra~ture despite fixation
the quality of the bone for internal fixation, the stability of the • Flexor and extensor tendon irritation
fixation, and the management of any associated soft tissue in- • Painful metal requiring removal
juries that were addressed during the arthro~opi~ evaluation. • Neuromas of the dorsal sensory brand of the radial and
• Inunediate range of motion of the digits and wrist is initi- ulnar nerves
ated in patients with volar plate fiXation with good bone stock • Carpal tunnel syndrome
and solid fixation. • Reflex sympathetic dystrophy
• In patients with soft osteopeni~ bone with volar plate fixa- • Wrist and hand stiffness
tion, digital range of motion exercises are initiated immedi-
ately, but wrist range of motion is delayed approximately 3 to REFERENCES
4 weeks to permit some fra~ture healing.
1. Bradway .JK, Amadio PC, Cooney WP. Open reduction and internal
Soft bone may oollapse around the rigid plate. fixation of displaced comminuted intraarticnlar fractures of the distal
• In patients without metaphyseal ~omminution treated by end of the radius. J Bone Joint Surg Am 1989;71A:839-847.
arthros~opkally assisted stabilization with ~annulated so-ews, 2. Doi K, Hatturi T, Otsuka K, et a!. Jntraarticnlar fractures of the dis-
range of motion is initiated as the patient tolerates. tal aspect of the radius arthroscopically assisted reduction compared
• In patients treated with per~utaneous K-wires, the wrist is with open reduction and internal fixation. J Bone Joint Surg Am
immobilized until the wires are removed, usually 4 to 6 weeks 1999;81A:1093-1110.
3. Edwards CCIII, Harasztic J, McGillivary GR, et al. Intraarticnlar dis-
after surgery. tal radius fractures: arthroscopic assesslllCnt of radiographically as-
• A patient with an unstable DRUJ treated by TFCC repair or sisted reduction. J Hand Surg Am 2001;26A:1036-1041.
ulnar styloid redu~tion and fixation is restricted from prona- 4. Fernandez DL, Geissler WB. TreatlllCnt of displaced articnlar frac-
tion and supination for 2 to 4 weeks. tures of the radius. J Hand Surg Am 1991;16:375-384.
5. Geissler WB. Arthroscopically assisted reduction of intra-articnlar
OUTCOMES fractures of the distal radius. Hand Clin 1995;11:19-29.
6. Geissler WB. lntra-articnlar distal radius fractures: the role of
• The literature is relatively sparse regarding the results of arthroscopy? Hand Clin 2005;21:407-416.
arthros~opiwly assisted fixation of displa~ed intra-arti~ular 7. Geissler WB, Freeland AE. Arthroscopically assisted reduction of
distal radius fra~tures. intra-articular distal radial fractures. Clin Orthop Relat Res 1996;
• A ~omparison study of 12 open and 12 arthros~opic reduc- 327:125-134.
tions of comminuted AO type VII and VIll fra~tures of the dis- 8. Geissler WB, Freeland AE, Savoie FH, et al. lntracarpal soft-tissue le-
tal radius found that the arthro~opic group had increased sions associated with an intra-articnlar fracture of the distal end of
the radius. J Bone Joint Surg Am 1996;78A:357-365.
range of motion as compared to the open stabilization
9. Geissler WB, Savoie FH. Arthroscopic techniques of the wrist.
group.23 Medignide to Orthopedics 1992;11:1-8.
• A second ~omparison study of 38 patients who underwent 10. Hanker GJ. Wrist arthroscopy in distal radius fractures. Proceedings
arthros~opiwly assisted fixation ~ompared to open redu~tion of the Arthroscopy Association North America Annual Meeting,
found the arthroscopiwly assisted group had better results Albuquerque, NM, October 7-9, 1993.
and improved range of motion.2 11. Hixon ML, Fitzrandolph R, McAndrew M, et al. Acute ligamentous
• One study compared 15 patients with arthros~opi~ally as- tears of the wrist associated with Colles fractures. Proceedings of tb.c
Annual Meeting of the AlllCrican Society for Surgery of tb.c Hand,
sisted fixation to 15 patients who underwent closed redu~tion Baltimore, 1989.
and external fixation. 21 In this study, there were 10 tears of 12. Hollingworth R, Morris J. The importance of the ulnar side of tb.c
the triangular fibro~lage ~omplex in the group that under- wrist in fractures of the distal end of the radius. Injury 1976;7:263.
went arthro~opi~ redu~tion, of whid seven were peripheral 13. Knirk JL, Jupiter JB. Intra-articular fractures of tb.c distal end of tb.c
and repaired. There were no signs of distal radioulnar joint in- radius in young adults. J Bone Joint Surg Am 1986;68A:647~58.
stability at final follow-up visit. In the 15 patients who under- 14. Lafontaine M, Hardy D, Delince P. Stability assessment of distal ra-
dius fractures. Injury 1989;20:208-210.
went stabilization by external fixation alone, four patients had 15. Levy HJ, Glickel SZ. Arthroscopic assisted internal fixation of intra-
~ontinued ~omplaints of instability of the distal radial joint, articnlar wrist fractures. Arthroscopy 1993;9:122-123.
very possibly the result of undiagnosed and untreated TFCC 16. Lindau T. Treatment of injuries to the ulnar side of the wrist occur-
tears. ring with distal radial fractures. Hand Clin 2005;21:417-425.

17. Melone CP. Articular fractures of the distal radius. Orthop 21. Short WH, Palmer AK, Werner FW, ct a!. A biomcchanical study of
North Am 1984;15:217-235. distal radial fractures. J Hand Smg Am 1987;12:529-534.
18. Mohanti RC, Kar N. Study of triangular fibrocartilage of the wrist 22. Stewart NJ, Berger RA. Comparison study of arthroscopic as open re-
joint in CoDes fracture. Injury 1979;11:311-324. duction of comminuted distal radius fractures. Abstract. Presented at
19. Mudgal CS, Jones W A. Scapholunatc diastasis: a component of frac- the 53rd Annual Meeting of the American Society for Smgcry of the
tures of the distal radius. J Hand Smg Br 1990;15:503-505. Hand. January 11, 1998, Scottsdale, AZ.
20. Ruch DS, Vallee J, Poehling GG, ct a!. Arthroscopic reduction versus 23. Trumble TE., Schmitt SR, Vedder NB. Factors affecting functional
fluoroscopic reduction in the management of intra-articular distal ra- outcome of displaced intra-articular distal radius fractures. J Hand
dius fractures. Arthroscopy 2004;20:225-230. Smg Am 1994;19:325-340.
- Fragment-Specific Fixation of
Chapter 10 Distal Radius Fractures
f Robert J. Medoff

DEFINITION • The goal of fragment-specific fixation is to create a multi-

planar, load-sharing construct that anatomically restores the
• Fragment-specific fixation is a treatment approach in which
articular surface and bas enough stability to allow immediate
each major fracture component is identified and fixed indepen-
motion after surgery.
dently using low-profile implants with a certain degree of
"'spring-like" elasticity.
• Each fracture component has a Wlique implant specifically ANATOMY
designed for that particular fracture element (FIG 1 ). • The radial column fragment is formed from the pillar of
• Surgical planning is extremely important to determine bone along the radial border (FIG 2 ). This fracture component
whether a single approach or a combination of surgical ap- is important to maintain radial length to support the carpus in
proaches is needed to visualize and fix each of the main frac- its normal spatial position. The brachioradialis inserts on the
ture components present in a particular injury. base of the radial column and may result in shortening of the
• At the start of surgery, a complete set of implants should be radial column fragment, leading to impaction of the carpus
available to address fractures of the radial column, ulnar cor- into remaining fragments. Metaphyseal conuninution may
ner, volar rim, dorsal wall, and free impacted articular frag- also contribute to radial column instability.
ments. In addition, identification and treatment of distal • The volar rim of the lunate facet is a primary load-bearing
radioulnar joint (DRUJ) disruptions or unstable fractures of structure of the articular surface. Instability of the volar rim
the ulnar column may be required. occw:s in two patterns:
• As a rule, this technique avoids creating large holes in small In the volar instability pattem, shortening and volar
distal fragments, with fixation based and often triangulated to translation of the volar rim result in secondary volar sublux-
the stable ipsilateral cortex of the proximal fragment. ation of the carpus.

Radial pin plate Ulnar pin plate Volar buttress pin

Small fragment clamp Dorsal buttress pin

FIG 1 • Fragment-specific implants.


Radial column into the articular surface, this fragment migrates dorsally and
shortens proximally. Residual displacement of the ulnar cor-
Ulnar comer ner can result in instability of the DRUJ as weD as restriction
of forearm rotation.
• Dorsal wall fragmentation typically OCCU1"8 with either dor-
sal bending injuries or axial loading injuries and may con-
tribute to fracture instability.
• Free articular fragments may be impacted within the meta-
physeal cavity and result in incongruity of the articular surface.

• Dorsal bending injuries result in extra-articular fractures
Dorsal wall with dorsal displacement (FIG !A). Comminution of the
metaphyseal cavity or dorsal wall usually suggests a dorsally
unstable fracture pattern.
• Volar bending injuries result in extra-articular fractures with
A volar displacement (FIG !B). Fractures with significant volar
Intra-articular displacement are nearly always unstable and require some type
of intervention to obtain and hold a reduction until union.
• Dorsal shearing injuries present as fractures of the dorsal
rim and are often associated with dorsal instability of the car-
pus (FIG !C).
• Volar shearing injuries present as displaced fractures of the
volar rim and .result in volar instability of the carpus (FIG !D).
Often, this pattern is comminuted and hlghly unstable and not
suited to dosed methods of treattnent.
• Simple three-part fractures are usually the .result of low-
energy injuries that combine an axial loading and dorsal bend-
FIG 2 • Articular fracture components. ing mechanism (FIG 3E). This pattem is characterized by the
presence of an ulnar comer fragment that involves the dorsal
portion of the sigmoid notch, a main articular fragment. and a
In the axial instability pattern of the volar rim, axial im- proximal shaft fragment.
paction of the carpus drives the volar rim into dorsiflexion, • Unstable fractures with complex involvement of the articu-
resulting in seoondary axial and dorsal subluxation of the lar surface to simplify complex articular fractures. In addition
carpus. to articular comminution, this pattem may often generate a
• The ulnar corner fragment involves the dorsal half of the significant defect in the metaphyseal cavity or complete disrup-
sigmoid notch. Typically a result of impaction of the lunate tion of the DRUJ (FIG 3F).


FIG 3 • Pathogenesis of dorsal radius fractures. A.

Dorsal bending. B. Volar bending. C. Dorsal shear.
c (continued)
93 -

FIG 3 • (continued) D. Volar shear. E. Three-part articular. F. Comminuted articular. G. carpal avulsion. H. High energy.

• The avulsion and carpal instability pattern is primarily a lig- horizon identifies the volar rim. However, if the articular
amentous injury of the carpus that has associated osseous surface is in dorsal tilt, the x-ray beam is parallel to the
avulsions of the distal radius (FIG 3G). subchondral bone of the dorsal half of the lunate facet and
• Extremely high-energy injuries present as complex fractures the carpal facet horizon identifies the dorsal rim (not
involving comminution of the articular surface as weD as ex- shown). The carpal facet horizon is the portion of the
tension into the radial or ulnar shaft (FIG 3H). articular surface that is visualized on the 10-degree lateral
x-ray projection.
IMAGING AND OTIIER DIAGNOSTIC Teardrop angle (normal 70 :t 5 degrees; FIG SC.D).
sTUDms The teardrop angle is used to identify dorsiflexion of the
• Posteroanterior (PA), standard lateral (FIG 4.A,B), and tO- volar rim of the lunate facet. Depression of the teardrop
degree lateral views are routine views for radiographic evalua- angle to a value less than 45 degrees indicates that the
tion of the distal radius. The 10-degree lateral view (FIG volar rim of the lunate facet has rotated dorsally and
4(,D) clearly visualizes the ulnar two thirds of the articular impacted into the metaphyseal cavity (axial instability
surface from the base of the scaphoid facet through the entire pattern of the volar rim). This may be associated with
lunate facet. Oblique views may also be helpful for evaluating axial and dorsal subluxation of the carpus. Restoration of
the injury. the teardrop angle is necessary to correct this type of
• The radiographic features of distal radius fractures include malreduction.
the following: Articular concentricity (FIG 5E,F). The subchondral
Carpal facet horizon (FIG 5.A,B). This is the radiodense outline of the articular surface of the distal radius is nor·
horizontal landmark that is used to identify the volar and mally congruent and concentric with the subchondral out-
dorsal rim on the PA view. If the articular surface is in pal- line of the base of the lunate; a uniform joint interval
mar tilt, the x-ray beam is parallel to the subchondral bone should be present between the radius and lunate along the
of the volar half of the lunate facet and the carpal facet entire articular surface. When these articular surfaces are

FIG 4 • A. Positioning for standard lateral radiography. B. Standard lateral radiograph. C. Positioning
for 10-degree lateral radiography. D. Ten-degree lateral radiograph. Note the improved visualizauon of
the articular surface of the base of the scaphoid facet and the entire lunate facet.


c D
FIG 5 • A. carpal facet horizon (atYOws}. Used to differentiate between the volar and dorsal rim on
the PA projection. B. Origin of carpal facet horizon. The carpal facet horizon is formed by that part
of the articular surface that is parallel to the x-ray beam and depends on whether the articular sur-
face is in volar or dorsal tilt. C. Normal teardrop angle. D. Depressed teardrop angle, in this case
caused by axial instability of the volar rim. (continued)
95 -


FIG 5 • (continued) E. Normal articular concentricity. F. Abnormal articular concentricity, indicating disruption across the volar
and dorsal surfaces of 1he lunate facet. G. AP interval is the point-to-point distance between the corners of 1he doBal and
volar rim. H. Distal radioulnar joint interval. 1. Normal lateral carpal alignment. J. Dorsal subluxation of the carpus.

not concentric, discontinuity and disruption of the lunate presence of other associated injuries that may affect the deci-
facet has occurred. sion for a particular treatment.
AP distance (normal: females 18 :!: 1 mm, males 20 :!:
1 mm; FIG SG). The AP distance is the point-to-point SURGICAL MANAGEMENT
distance from the dorsal corner of the lunate facet to the Operative Indications
palmar corner of the lunate facet. It is best evaluated on • Galeral parameters:
the tO-degree lateral view. Elevation of the AP distance in- Shortening of more than 5 mm
dicates disruption of the volar and dorsal portion of the Radial inclination of less than 15 degrees
lunate facet. Dorsal angulation of more than 10 degrees
DRUJ interval (FIG SH). The DRUJ interval measures the Articular stepoff of more than 1 to 2 rwu
apposition between the head of the ulna and the sigmoid Depression of teardrop angle of less than 45 degrees
notch. Significant widening of the DRUJ interval implies dis- • Volar instability
ruption of the DRUJ capsule and triangular fibrocartilage • DRUJ instability
complex (1FCC).
• Displaced articular fractures
Lateral carpal alignment (FIG SI~J). The center of rota- • Young. active patients are generally less tolerant of residual
tion of the capitate normally lines up with a line extended deformity and malposition.
from the volar surface of the radial shaft with the wrist in
neutral position. Dorsal rotation of the volar rim results in Preoperative Planniug
dorsal subluxation of the carpus from this normal position, • Extra-articular fractures: multiple options:
placing the flexor tendons at a mechanical disadvantage, Volar plating through a volar approach
which may affect grip strength. Dorsal plating through a dorsal approach
• In addition to the injury fihns, it is important to reassess Fragment-specific fixation
postreduction views to determine the personality and specific Radial pin plate (TriMed. Inc., Valencia, CA) and volar
components of the fracture. buttress pin (TriMed, Inc.) fixation through a limited in·
• cr scans allow higher resolution and definition of fracture cision volar or standard volar approach
characteristics, particularly for highly comminuted fractures. Radial pin plate and either an ulnar pin plate dorsally
Preferably, an attempt at closed reduction is done before aCT or a dorsal buttress pin through a dorsal or combined
scan is obtained to limit distortion of the image. CT scans are approach
particularly helpful for visualizing intra-articular fragments as • Intra-articular fractures: surgical approach is based on the
well as DRUJ disruption. fragmentation pattern
• Clinical and radiographic evaluations of the carpus, in- Unstable volar rim fragments require a standard volar or
terosseous membrane, and elbow are used to identify the ulnar-volar approach for adequate visualization.

Fixation of the radial column can be done through either Operative Sequence
a limited-incision volar-radial approach, a volar approach • Radial column length is restored .first with ttaction; a
with a radial extension combined with pronation of the transstyloid pin is inserted to hold the reduction if needed.
forearm, or a dorsal approach with radial extension com- • The volar rim is reduced and fixed.
bined with supination of the forearm. • The dorsal ulnar corner is reduced and fixed.
Fixation of dorsal, ulnar comer, and free intra-articular • Free intra-articular fragments and the dorsal wall if needed
fragments can be done through a dorsal approach. are reduced and stabilized.
Positioning • Bone graft is applied if the metaphyseal defect is large.
• The patient is supine. • Fixation is completed with a radial column plate.
• The affected arm is on an armboard out to the side.
• C-arm
If the armboard is radiolucent, the C-arm can be brought • The repair is undertaken by means of one of the following
in from the end of the armboard and images taken direcdy approaches:
with the wrist on the armboard. Limited-incision volar approach
If the annboard is not radiolucent, the C-arm is brought Dorsal approach
in along the side of the table from the foot, and the arm is Extensile volar approach
brought off the armboard for each image. Volar-ulnar approach


• Make a longitudinal incision along the radial side of the Reflect the insertion of brachioradialis to expose the ra-
radial artery. dial column (IECH RG 11).
• Proximally, insert the tip of a tenotomy scissors over the • If needed, the dissection can be continued through the
surface of the first dorsal compartment sheath and floor of the incision to expose the volar surface. Detach
sweep distally to elevate a radial skin flap. the insertion of the pronator quadratus radially and dis-
• Pronate the forearm and sharply expose the bone over tally and reflect it to the ulnar side. Alternatively, create
the radial styloid in the interval between the first and an ulnar skin flap superficial to the artery and continue
second dorsal compartments (IECH FIG 1A). the exposure through a standard volar approach.
• Leaving the distal 1 em of sheath intact, open the first • This approach cannot be used to access the ulnar side of
dorsal companment proximally and mobilize the tendons. the volar rim.

0 Roh..,rc J 1\1t.'dorT. MD 2006

. B Brach ioradialis (reflected)

TECH FIG 1 • Limited-incision volar approach. A. sweeping tenotomy
scissors to elevate radial skin flap off first dorsal compartment. B. Deep
A exposure of the radial column.
• Make a longitudinal skin incision dorsally along the ulnar • Develop the interval between the fourth and fifth extensor
side of the tubercle of Lister (.TECH FIG 2A}. compartments to gain access to the ulnar corner fragment.
• Identify the extensor digitorum communis (EDO tendons • A dorsal capsulotomy can be done to visualize the artic-
visible proximally through the translucent extensor ular surface and carpus if necessary.
sheath. Incise the dorsal retinacular sheath. • To gain access to the radial column through a dorsal
• Develop the interval between the third and fourth exposure, extend the incision as needed and elevate a
compartment tendons for access to dorsal wall and free, radial subcutaneous flap and supinate the wrist.
impacted articular fragments. Resect a segment of the • To gain access to the distal ulna, extend the incision as
terminal branch of the posterior interosseous nerve needed and elevate an ulnar subcutaneous flap.
(IEat RG 28).
• Transpose the extensor pollicis longus (EPL} from the
tubercle of Uster if required for additional exposure•



TECH RG 2 • Dorsal approach. A. Initial incision. B. Deep exposure.


• Start the skin incision at the distal pole of the scaphoid • If access to the radial column is needed, elevate a radial
and angle it toward the radial border of the flexor wrist subcutaneous flap superficial to the radial artery and first
crease, then extend it proximally along the flexor carpi dorsal compartment tendon sheath. Pronate the wrist and
radialis (FCR) tendon (IECH RG 3A). retract the radial skin flap to expose the radial column.
• Open the FCR tendon sheath both proximally and distally
and continue in the plane between the FCR tendon and
the radial artery (.TECH FIG 31).
• Use blunt dissection with a finger or sponge to sepa-
rate the interval between the contents of the carpal
tunnel and the surface of the pronator quadratus.
Retract the FCR.. median nerve, and flexor tendons to
the ulnar side.
• Divide the radial and distal attachment of the pronator
quadratus and reflect it to the ulnar side. Limit the distal
dissection to no more than 1 or 2 mm beyond the distal
radial ridge to avoid detachment of the volar wrist cap-
sular ligaments (.TECH FIG 3C).
• Reflect the brachioradialis from its insertion on the distal TECH RG 3 • Extensile volar
fragment if needed. Bone graft can be applied through approach. A. Initial incision.
the radial fracture defect. A (contlnued)

TEat FIG 3 • (continued) I. Line of incision in

I c pronator quadratus. C. Deep exposure.

• Make a longitudinal skin incision along the ulnar border • Retract the contents of the carpal tunnel to the radial
of the flexor carpi ulnaris (FCU) tendon ClEat FIG 4A). side ClEat FIG 4 C).
• Reflect the FCU tendon and the ulnar artery and nerve to • Reflect the pronator quadratus from its ulnar and distal
the ulnar side (IECH FIG 41}. attachment. Do not dissect more than 1 to 2 mm beyond
• With blunt finger or sponge dissection. develop the plane the distal radial ridge to avoid detaching the volar wrist
on the superficial surface of the pronator quadratus. capsule.

A I c
TECH AG 4 • Volar-ulnar approach. A. Incision. B. Initial exposure. C. Completed exposure.


• Expose the radial column with any of the approaches first dorsal compartment proximally, leaving the last 1
previously described. Sharply expose the interval be- em of tendon sheath intact.
tween the first and second dorsal compartments over the • Retract the tendons of the first dorsal compartment dor-
tip of the radial styloid. Release the tendon sheath of the sally or volarly as needed. Release the terminal insertion
of the brachioradialis to complete exposure of the radial to limit penetration of the Kirschner wire through the
column. far cortex to 1 to 2 mm.
• After the initial fracture exposure, restore radial length • Mark a reference point where the Kirschner wire crosses
with traction and ulnar deviation of the wrist. If needed, the surface of the plate. Withdraw the Kirschner wire
structural bone graft can be inserted through the radial 1 em and cut it 1 em or more above the reference mark
fracture defect. (IECH RG SB).
• Insert a 0.045-inch transstyloid Kirschner wire angled to
engage the far cortex of the proximal fragment (IECH
• Position the reference mark between the lower two
posts of a wire bender and create a hook (TEat FIG
FIG SA}. When the advancing tip of the Kirschner wire 5C). The bend should start at the reference mark
hits the far cortex. place a drill sleeve over the Kirschner to make a Kirschner wire of proper length when
wire to use as a drill stop to limit penetration of the far completed.
cortex to 1 to 2 mm. • Complete the bend with a pin clamp, overbending
• Once the radial column is temporarily fixed with a
transstyloid Kirschner wire, reduce and stabilize other
slightly to allow the hook to snap into an adjacent pin
hole or over the edge of the plate. Wrth a free 0.045-inch
volar, dorsal, and articular fracture elements before com- Kirschner wire, predrill a hole to accept the end of the
pleting foortion of the radial column. hook (TECH FIG 5D}.
• select a distal pin hole and slide a radial pin plate over
the transstyloid Kirschner wire. Proximally, guide the
• Impact the Kirschner wire with a pin impactor and fully
seat the hook (IEat FIG SE). Repeat the procedure with
plate under the tendons of the first dorsal compart- the second Kirschner wire.
ment and secure it initially with a single 2.3-mm bone • Complete proximal fixation with 2.3-mm cortical bone
screw. screws (TEat FIG 5F,G}.
• Insert a second transstyloid Kirschner wire through a
non-adjacent distal pin hole. Use the previous technique

TEat FIG 5 • Radial column fixation. A. Insertion of transstyloid Kirschner wire. B,C. Creation of pin hook.
D,E. Completion and impaction of pin hook. F,G. Completed radial column fixation.


Ulnar Pin Plate • Slide the plate over the Kirschner wire and fix it proxi-
mally with a 2.3-mm bone screw (IEat FIG 6 C).
• Through a dorsal approach, expose and reduce the dor-
• Insert a second Kirschner wire if the fragment is large
sal ulnar corner fragment, dorsal wall fragment, or both.
enough. Create and impact hooks as described for the ra-
• Insert a 0.045-inch Kirschner wire through the fragment
dial pin plate (IEat FIG 6 D-E}.
(IEat FIG SA), angled proximally and slightly radially to
• If the Kirschner wire tips protrude beyond the volar cor-
purchase the far cortex of the proximal fragment.
tex. they can be cut flush to the bone surface through a
• Insert structural bone graft into the metaphyseal defect
volar incision.
if present to support the subarticular surface.
• If the plate is aligned over the ulnar half of the shaft,
add a 15-degree torsional bend to the plate (twist the Dorsal Buttress Pin
proximal end of the plate into slight supination}. Often, • Through a dorsal approach, expose and reduce the dor-
a little extra extension can be contoured atthe distal end sal ulnar corner fragment, dorsal wall fragment, or
of the plate (IECH FIG 61}. both.

TEat FIG 6 • Ulnar corner flXBtion with an ulnar pin

plate. A. Insertion of the interfragmentary Kirschner
wire. B. Contouring the plate. C. Application of the
plate and insertion of the initial fixation screw.
D. Fixation completed. f,F. Radial and ulnar pin
plate fiX.auon of a three-part articular pattern (radial
column and ulnar comer fragment).
• Insert structural bone graft into the metaphyseal defect than the radial leg so one leg can be engaged at a
if present to support the subarticular surface. time.
• Insert two 0.045-inch Kirschner wires through the dorsal • Place the ulnar leg of the buttress pin adjacent to the in-
cortex and behind the subchondral bone; ched the posi- sertion site of the ulnar Kirschner wire, and then with-
tion with the C-arm (IECH FIG 7A). The Kir$Chner wires draw the Kirschner wire and immediately engage the leg
should be separated by about 1 em and should be trans- in the hole. Repeat with the radial Kirschner wire to en-
verse to the longitudinal axis of the shaft. Initially placing gage the radial leg of the buttress pin. Impact and seat
a dorsal buttress pin upside-down on the bone is helpful the buttress pin ('IEat FIG 7D).
to use as a template to visualize the proper position and • Fine-tune the reduction and complete the fixation prox-
insertion angle of the KiBchner wires ClEat FIG 78). imally with one or two 2.3-mm cortical bone screws and
• Ensure that the leading tips of the legs of the dorsal washers (IECH FIG 7E,.F).If needed, a blocking screw can
buttress pin are straight and cut to the required length be placed just proximal to the end of the buttress pin to
('IEat FIG 7C). Leave the ulnar leg 2 to 3 mm longer prevent shortening of the fragment.



'IEat FIG 7 • Dorsal buttress pin fixation. A. The position of the Kirschner wires is checked with a C-arm before inserting the
implant. B. Placing an implant upside-down on bone to template the trajectory of the Kirschner wires. C. Inserting the dor-
sal buttress pin. D. Buttress pin fixation completed. E,F. Fixation of a three-part articular fracture with radial column and
ulnar corner fragment with radial column plate and dorsal buttress pin.


Small-Fragment Plate Fixation and strength to allow distal locked screw purchase to ob-
tain angular correction of the dorsiflexion deformity.
• Small-fragment volar plate fixation may be indicated for
treatment of a volar instability pattern of the volar rim. • An appropriate volar approach is used to expose the
volar rim fragment. If a shortened radial column frag-
The fragment must be of adequate size to allow buttress-
ment is present, first restore radial length and provision-
ing on the volar surface by the plate (1Eat FIG &A,B).
ally hold it with a transstyloid Kirschner wire to unload
• If volar rim fragmentation is associated with an axial in-
the lunate facet.
stability pattern, the fragment must be of adequate size

TEat FIG 8 • Volar rim fixation

with small-fragment plate. A.B.
Shear fracture of volar rim with
volar instability pattern. c;.D.
Fixation with small-fragment

• Reduce the volar rim fragment; this should restore nor- as possible and note the orientation of the teardrop on
mal carpal alignment. the 10-Gegree lateral view.
• Apply a small-fragment volar plate and fiX it proximally • Insert two 0.045-inch Kirschner wires transverse to one
with cortical bone screws. If needed, secure the distal another starting at an entry site 1 to 2 mm beyond the
fragment with standard or locking bone screws (IEat distal radial ridge. They should be placed within the cen-
FIG SC.D). ter of the teardrop on the lateral view. Confirm the po-
sition of the Kirschner wires with C-arm.
Volar Buttress Pin Fixation • If necessary, the volar buttress pin may be contoured with
a wire bender to match the flare of the volar surface of the
• Volar buttress pin fixation is indicated for unstable volar
rim fragments and can be a particularly effective tee~ distal radius. Adjust the trajectory of the legs of the im-
nique when faced with small distal fragments or axial in- plant to make a 70-Gegree angle widl the base of the wire
stability patterns of the volar rim (depressed teardrop form. Cut dle legs to appropriate length, leaving the ulnar
angle; TEat FIG 9A,B}. leg 2 to 3 mm longer than the radial leg (.TEat FIG 9D.E).
• Use an appropriate volar approach to expose the volar • Noting the entry site of the Kirschner wire, carefully ~
rim fragment. If necessary. restore radial length and pro- move the ulnar Kirschner wire and engage the ulnar leg
visionally hold it with a transstyloid Kirschner wire to un- of the volar buttress pin. Repeat the procedure with the
load the lunate facet (IECH FIG 9C). radial leg. Impact and seat the implant into the volar rim
• Continue exposure for up to 1 to 2 mm beyond the dis- fragment (IEat FIG 9F).
tal radial ridge. Reduce the volar rim fragment as much • Fine-tune the reduction and fix it proximally with a min-
imum of two screws and washers (IEat FIG tG.H).

A B c
TEat FIG 9 • Volar rim fixation with a volar buttress pin. A.B. Articular fracture with axial instability pattern of
volar rim. C. Insertion of Kirschner wires. (continued)
103 -

TEat FIG 9 • (continued) D. Cutting

and inserting legs. E. Reduction of
teardrop. F. Completed fixation.
G.H. Volar buttress pin fixation to
control rotational alignment of volar
G rim fragment.


• Free articular fragments impacted into the metaphyseal shell, resulting in containment of the graft within the
cavity require both a buttress to support the subchondral metaphysis.
surface and circumferential peripheral cortical stability • The dorsal buttress pin can also be used for direct sub-
to prevent displacement (IEat FIG 10A). chondral support of impacted articular fragments. The
• In some cases, impacted free articular fragments may be legs of the implant are cut to length and inserted
adequately supported by a properly applied lodcing through the dorsal defect, slid distally directly behind
plate that provides subchondral support. the articular fragment, and then fixed proximally with a
• An alternative method is to use structural bone graft to screw and washer (IEat FIG 1CB}. The articular frag-
support the free articular fragment in combination with ment is sandwiched between the base of the lunate and
fragment-specific fixation of the surrounding cortical the legs of the implant (IECH FIG 10C).

TEat RG 10 • A. Depressed ar-

ticular fragment. B. Support of
free articular fragment with a
buttress pin. C. Dorsal buttress
pin to support fragment from
c endosteal surface.


Determining whether a • Correlate the carpal facet horizon with the lateral view to determine whether a fragment is
fragment is volar or dorsal on dorsal or volar.
the PAview • If the articular surface is tilted dorsally, the carpal facet horizon identifies the dorsal rim.
• If the articular surface is tilted volarly, the carpal facet horizon identifies the volar rim.
Reduction of unstable fracture • Identify and start reduction with the fragment that stabilizes the carpus to its normal spatial
pattern relationship. Often, initial reduction of the radial column with a provisional transstyloid
Kirschner wire will restore carpal length. Alternatively, when this fragment is comminuted,
fixation of the volar rim is often successful for reduction of the carpus.
• Adding structural bone graft. either through the fracture line at the base of the radial column
or through a dorsal defect, can help stabilize the reduction during operative fixation.
Widening of the DRUJ or • Make sure the distal articular fragments are translated toward the ulna before completing
carpal translation volar fixation.
• An elastic. slightly overcontoured radial column plate can help close sagittal fracture gaps and
seat the sigmoid notch against the ulnar head.
• Assess the clinical stability of the DRUJ and consider TFCC repair or suture or fixation ofthe
ulnar styloid if needed.
Small or dorsally rotated volar • Ensure adequate fixation of volar-ulnar corner fragment.
rim fragment; loss of fixation • Consider volar buttress pin fixation for an extremely distal or dorsally rotated volar rim fragment.
of small volar-ulnar fragment • Avoid release of the volar wrist capsule. When necessary, the legs of the implant can be
inserted through the capsule.
• If needed, the volar buttress pin can be contoured as needed to match the arc of curve ofthe
flare of the volar shaft.
Unrecognized carpal ligament • Maintain a high index of suspicion for ligamentous injuries ofthe carpus. Consider arthroscopic
injury evaluation, particularly in the context of radial or dorsal shear fractures, carpal avulsion and
instability patterns, or articular fractures associated with a significant longitudinal stepoff
between the scaphoid and lunate facets.
Missed fragment: fracture • Careful analysis of radiographic features both before and during reduction; a scan when needed
displacement after surgery • Preoperative planning to select approaches that allow complete visualization of all major
• Complete set of implants and instruments available before surgery
Loss of radial length: proximal • Graft the metaphyseal defect when needed with structural bone graft.
migration of articular surface • Use implants that buttress the subchondral bone.
DRUJ dysfunction: pain, • Assess clinical stability of DRUJ at end of procedure.
instability, or limitation of • Use radial column plate to push distal fragment against ulna to seat sigmoid notch against
forearm rotation ulnar head.
• Evaluate and repair TFCC and capsular tears when necessary.
• Reduce and fix ulnar corner and volar rim fragments to restore congruity of sigmoid notch.
• Ensure that radial length is restored.
Stiffness: slow, restricted return • Early range of motion and mobilization of soft tissues
of movement of wrist. forearm, • Avoidance of constricting bandages and postoperative swelling
and fingers, often associated
with pain
Tendinitis or rupture: pain • Use implants that have a low distal profile.
with resisted motion, loss of • Avoid placing sharp, bulky edges of hardware in proximity to tendons.
tendon function, clicking and • Cover plates distally with retinacular flap when needed.
pain • Consider use of buttress pins (which have a very low profile) when possible.
• Remove any pins or hardware that back out or become prominent postoperatively.
• Ensure that volar plates do not extend up beyond distal volar ridge into soft tissues.
• Avoid long screws or pins, particularly when placed from volar to dorsal. Distal screws should
normally be 2 to 4 mm shy of the dorsal cortical margin.

POSTOPERATIVE CARE compliant patients or injuries with tenuous fixation, use a cast
• At the end of the surgkal pro~edure, ~onfum the stability of for 2 to 3 weeks postoperatively.
fixation as well as the stability of the DRUJ. • Avoid resistive loading across the wrist until signs of radi-
• If stable, apply a removable wrist bra~ and instru~t the pa- ographic healing are present; typically this occurs by 4 weeks
tient to initiate gentle range-of-motion exercises of the fingers, postoperatively. Specifically instruct older patients not to push
wrist, and forearm twice or more daily as tolerated. For non- up out of a chair or lift heavy objects after surgery.

• If there is persistent stiffness after 4 weeks, initiate physical osteoporosis, failure to graft the metaphyseal defect, and
and occupational therapy. associated DRUJ injuries may contribute to loss of reduc-
tion or malunion.
OUTCOMES Pin plates are able to resist translational displacements
• Konrath and Bahler4 reported 27 patients with at least 2 years but are less effective for preventing loss of length; they re-
of follow-up: quire osseous contact between the proximal and distal frag-
One fracture lost reduction. ments or additional support by a secondary implant that
Patient satisfaction was high (average DASH scores 17 will buttress the subchondral surface.
and PRWE scores 19 at follow-up). Nonunions are extremely rare.
In only three cases was hardware removed; no tendon • Tendinitis or tendon rupture: uncommon
ruptures occurred. If pins are noted postoperatively to back out, they should
• Schnall et aF reported on two groups of patients: group I be removed. Leaving the distal1 em of tendon sheath of the
had sustained high-energy trauma and group II had lower- frrst dorsal compartment intact helps avoid tendon contact
energy injuries. with hardware.
Group I patients averaged return to work in 6 weeks, with Using low-profile implants dorsally, covering the distal
all fractures uniting without loss of position or deformity. ends with a strip of retinacular sheath, or both is also helpful.
Two patients in group I required removal of painful The surgeon should avoid leaving screws or pins protrud-
hardware. ing from the dorsal or volar surfaces of the bone.
Group II patients averaged 2 degrees of loss of volar tilt, • Painful hardware: rare
a 0.3-mm change in ulnar variance, and no loss of joint con- Painful hardware can be related to migration of a pin or
gruity at follow-up. settling of the fracture proximally. Overbending pin hooks
Grip strength in group II patients was 67% of the con- and using bone graft or buttressing implants can help avoid
tralateral side. this problem.
• Benson et aJZ reported on 85 intra-articular fractures in 81 Remove hardware when painful.
patients with a mean follow-up of 32 months. • Late arthritis is uncommon and probably related to the
There were 64 excellent and 24 good results, with an av- quality of the articular restoration.
erage DASH score of 9 at final follow-up. • Infections, bleeding, carpal tunnel syndrome, and other nerve
Flexion and extension motion was 85% and 91% of the injuries are uncommon and often related to the primary injury.
opposite side at final follow-up. • Complex regional pain syndrome is rare and may be related
Grip strength was 92% of the opposite side at fmal to initiation of early motion after surgery.
Sixty-two percent of patients had a 100-degree arc of
flexion-extension and normal forearm rotation by 6 weeks REFERENCES
postoperatively. 1. Barrie I<. Wolfe S. Intcmal fixation for intraarticular distal radius
fractures. Tech Hand Up Extrem Surg 2002;6:10-20.
Postoperative radiographic alignment was maintained at
2. Beman LS, Minibane KP, Sum LA, et al. The outcome of intra-
follow-up. articular distal radius fractures treated with fragment-specific
There were no cases of symptomatic arthritis. fixation. J Hand Surg Am 2006;31A:1333-1339.
3. Fernandez DL, Jupia:r JB. Fractw:a of the Distal Radius, 2nd ed.
COMPLICATIONS Springer, 2001:42-50.
4. Konrath G, Bahler S. Open reduction and inu:mal fixation of unsta-
• Stiffness: common early, uncommon at follow-up ble distal radius fractures: results using the TriMed system. J Orthop
Recovery can be accelerated by anatomic fiXation that is Trauma 2002;16:578-585.
stable enough to start motion immediately after surgery. 5. Leslie BM, Medoff RJ. Fracture-specific fixation of distal radius frac-
The relative degree of trauma to the bone and soft tissues, tures. Tech Orthop 2000;15:336-352.
combined with underlying physiologic factors, is also a crit- 6. Medoff R. Essential radiographic evaluation for distal radius frac-
ical factor that can lead to slow recovery of motion or resid- tures. Hand Clin 2005;21:279-288.
7. Schnall S, Kim B, Abramo A, et al. Fixation of distal radius fractures
ual stif.fuess.
using a fragment specific sysu:m. Clin Orthop Relat Res 2006;445:
• Malunion or nonunion: rare 51-57.
Loss of reduction may occur, particularly if a major frac- 8. Swigart C. Wolfe S. Limia:d incision open techniques for distal radius
ture component is missed and left untreated. In addition, fracture management. Orthop Clin North Am 2001;30:317-327.
- Intramedullary and Dorsal
Chapter 11 Plate Fixation of Distal
Radius Fractures
t Pedro K. Beredjiklian and Christopher Doumas

DEFINITION The fourth compartment, containing the extensor indicia

proprius and extensor digitonun communis, lies over the
• Distal radius fractures typically originate in the radial meta·
dorsal-ulnar distal radius.
physis and occasionally enter the radiocarpal joint and distal
The fifth compartment, containing the extensor digiti
radioulnar joint.
minimi, lies over the distal radioulnar joint.
• These fractures may be stable or Wl.Stable, intra-articular or
The sixth compartment, containing the extensor carpi ul-
extra-articular, and can be associated with various other bony
naris, lies over the distal ulna.
and soft tissue injuries about the wrist.
• Distal radius fractures are most commonly dorsally dis-
placed or angu.lated (apex volar). PAlHOGENESIS
• Treatment is based on fracture stability, comminution, artie· • Distal radius fractures typically occur due to a fall on an
ular segment displacement, articular surface displacement, and outstretched hand.
the functional demand of the patient. • Fractures occur when the force of axial loading exceeds the
• Stability is related to initial dorsal angulation, residual failure strength of cortical and trabecular bone.'
dorsal angulation after closed reduction, dorsal comminu· • The fracture pattern is determined by the magnitude and
tion, age of the patient, and associated distal ulna fracture direction of the force applied and the position of the hand
and intra-articular fracture extension.7•8 during impact.3
• Dorsally displaced or angulated fractures occur when the
ANATOMY wrist is neutral or extended and an axial or dorsally directed
• The distal radius has articulations at the scaphoid fossa, lu- force is applied to the carpus.
nate fossa, and sigmoid notch. • Osteoporosis, metabolic bone diseases, and bony tumors are
• The normal bony anatomy includes volar tilt of 10 degrees, risk factors for fracture.
radial height of 11 mm, and radial inclination of 22 degrees.
• Ulnar variance (the length of the radius relative to the ulnar NATURAL HISTORY
head at the sigmoid notch) is variable and patient dependent.
• Distal radius fractures are either stable or Wl.Stable.
• Dorsal ligamentous structures include the dorsal intercarpal
• Stable fractures, treated nonoperatively, historically have
ligament and the dorsal radiocarpal ligament.
excellent outcomes in terms of range of motion, pain, strength,
• The dorsal radiocarpal ligament originates from the dorsal
and function. 1
lip of the radius and attaches on the ulnar carpus.
Nonoperative management consists of immobilization
• The dorsal intercarpal ligament represents a capsular with either a cast or a splint, molded to prevent dorsal
thickening on the dorsum of the carpus, with fiber aligrunent
perpendicular to the long axis of the radius.
• Displaced, unstable, and comminuted fractures often require
• Volar ligamentous origins include the radioscaphocapitate
operative treatment.
ligament, the long radiolunate ligament, and the short radiolu-
• The goals of surgical treatment are to provide stability and
nate ligament, among others.
improve bony alignment in order to achieve pain control, im·
• The triangular fibrocartilage complex (I'FCC) consists of
prove range of motion, and increase function. 1•6
the triangular fibroc:artilage and volar radioulnar and dorsal
radioulnar ligaments.
• The volar radioulnar and dorsal radioulnar ligaments orig· Extensor
inate form the volar and dorsal edges of the sigmoid notch Extensor digiiDrum communis polllcls Extensor carpi
respectively, and become confluent and insert at the base of and extensor lndlcls proprius longus radialis brevis
the ulnar styloid. Extensor Extensor carpi
• The extensor retinaculum lies superficial to the extensor ten· digiti mlnlml racialis longus
dons and deep to the subcutaneous tissues. It has septations Extensor
creating six dorsal compartments (FIG 1 ). polllcls
•r.'~ ··- brevis
The first compartment lies over the radial styloid and con·
tains the abductor pollicis longus and the extensor pollicis :Abductor
poll leis
brevis tendons (each may have multiple slips). r\. f longus
The second compartment, containing the extensor carpi
radialis longus and extensor carpi radialis brevis, lies radial .......:;;=~-::--:::---~-- ' ~xtensor
to the tubercle of Lister.
The third compartment, containing the extensor pollicis FIG 1 • Anatomy of the distal radius. The six dorsal extensor
longus, lies ulnar to the tubercle of Lister. compartments at the level of the extensor retinaculum.

107 -

• One to 2 JWD or more of displacement of the articular sur- IMAGING AND OlHER DIAGNOSTIC
face of the distal radius leads to degenerative changes in yoWJg STUDIES
• Posteroanterior (PA), lateral, and oblique radiographic
• Dorsal angulation of more than 20 degrees from normal
views are critical in evaluating all suspected distal radius
(10 degrees dorsal tilt) can lead to pain, decreased range of
motion, and decreased grip strength.10
Consider imaging the uninjured wrist for comparison and
• Radial shortening can decrease range of motion and cause to serve as a template for surgical reconstruction.
pain with ulnar impaction of the carpus. to
Radiographs of the elbow should be obtained in almost
all cases, especially if any tenderness, swelling, or deformity
PATIENT fDSTORY AND PHYSICAL is detected clinically.
FINDINGS • Radiographic measurements taken .from the PA view
• A history of trauma is the most common patient presentation. (FIG 2A) indud~·13 :
• Pathologic fract:u.res may occur with minimal stress or trauma. Radial inclination, which is the angle between a line per-
• Patients complain of localized pain and present with pendicular to the shaft of the radius at the articular margin
swelling. decreased range of motion, and ecchymosis about the and a line along the radial articular margin
fracture. Normal angle= 21 degrees
• A history of previous fractures in an older patient should alert Radial length, which is the distance from a line tan-
the physician to the possibility of underlying osteoporosis. gential to the ulnar articular margin to a line drawn per-
• The skin should be carefully examined to rule out the pres- pendicular to the long axis of the radius at the radial
ence of an open fracture and to assess swelling before surgery or styloid tip
casting. If the wrist is markedly swollen or if swelling is antici- Normal length = 11 mm
pated, casting should be delayed and a splint should be placed. Ulnar variance, which is the distance from a line perpen-
• Neurologic symptoms in the form of numbness, tingling, dicular to the long axis of the radius at the sigmoid notch
and radiating pain into the digits should alert the physician to and a line tangential to the ulnar articular surface
the possibility of acute carpal tunnel syndrome. Careful neuro- Ulnar variance is variable, so to establish a normal
logic assessments should be performed to rule out the presence value, radiographs of the normal contralateral side should
of a progressive neurologic deficit. be obtained.
• Acute carpal tunnel syndrome represent! a surgical emergency. • Lateral articular (volar) tilt is the angle between a line for
• Examination: the articular surface of the radius and a perpendicular line to
Remove splints and dressings to visualize all areas of skin. the long axis of the radius.
Palpate for areas of tenderness or deformity. Palpate Normal angle = 11 degrees volar tilt (FIG 28)9•13
anatomic snuffbox. • Cf scans can fully elucidate the anatomy of the fracture,
Visualize and palpate the elbow for swelling, ecchymosis, particularly articular disruption or incongruity, and also help
tenderness, crepitus, and deformity. to determine the necessary surgical approach based on the lo-
Visualize and palpate the hand and fingers for swelling. cation and extent of coJWDinution.
ecchymosis, tenderness, crepitus, and deformity. cr scans increase the interobserver reliability of treat-
Use two-point tool or paper dip bent to 5 mm and touch ment plans and may actually alter the initial treatment plan
radial and ulnar aspects of all .fingers with one or two points. based on plain radiographs.5
Greater than normal (5 mm) two-point testing in the form of • MRI can be useful in evaluating for concomitant ligamen-
progressive neurologic deficit may signify an acute or chronic tous injuries, TFCC injuries, stress fractures, and occult carpal
carpal tunnel syndrome. fractures.

FIG 2 • A. PA radiograph demonstrating radial inclination, (black. lines),
ulnar variance (red), and radial height (white bracket). B. Lateral radi-
ograph of the wrist demonstrating volar tilt (black lines).

DIFFERENTIAL DIAGNOSIS dorsal plates and allow a less invasive option for fixation of
dorsally displaced fractures (FIG 3A,B).
• Bony contusion
• Indications for dorsal plating include:
• Wrist dislocation
Severe initial dorsal displacement (>20 degrees from nor-
• Scaphoid or other carpal fracture
mal, 10 degrees dorsal tilt)
• Carpal instability or dislocation
Marked dorsal co.rnntinution (greater than or equal to
• Distal ulna fracture
50% of the diameter of the radius shaft on the lateral
• Wrist ligament or lFCC sprain or tear
NONOPERATIVE MANAGEMENT Residual (after reduction) dorsal tilt greater than 10 de-
• Closed reduction should be performed in the emergency grees past neutral
department with longitudinal axial traction followed by 10 mm of radius shortening
volar displacement of the carpus. A bivalved, short-arm, weD- Dorsal intra-articular fragments displaced more than
1 mm1,6
molded cast or sugar-tong splint should be applied.
• Casting is the most commonly used method to definitively • Stabilization using an intramedullary device is indicated for
treat distal radius fractures and is preferred for nondisplaced distal radius fractures without extensive articular involvement
or minimally displaced fractures and those that are stable after in which a limited incision and shorter procedure are desired
a reduction maneuver (ie, restored volar tilt with minimal dor· (see Tech Fig 4E).
sal coiJUJ'Iinution). A precise three-point mold is required to Comminution of the volar metaphysis is a relative con·
maintain fracture reduction. traindication for the use of a dorsal intramedullary
• Removable splinting can be considered when treating com- implant.
pletely nondisplaced stable fractures in young adults. • The surgeon should be prepared to change management in-
• If nonoperative treatment is chosen, repeat radiographs traoperatively and must have additional stabilization options
should be taken on a weekly basis for the .6rst 3 weeks to ensure available, if necessary, such as percutaneous pins or an exter-
that the reduction is maintained. The physician should have a nal fixator.
low threshold for changing the cast.
• Any sign of dorsal migration indicates instability, and oper- Preoperative Planning
ative stabilization should be considered. • All radiographic imaging must be reviewed before surgery.
• Finger range of motion is begun immediately and wrist range It is helpful to compare radiographs of the injured wrist
of motion can be started as the fracture heals and is managed in to the uninjured wrist.
a removable splint. Displaced intra-articular fragments must be identified.
Dorsal comminution must be evaluated to determine frac-
SURGICAL MANAGEMENT ture stability and the need for bone grafting.
• Open reduction and internal fixation with a dorsal plate can The distal extent of the fracture must be determined to
be used succesafully in the treatment of displaced, Wlstable, enable the buttress plate to function properly.
comminuted fractures of the distal radius that fail to respond • Bone should be evaluated for osteopenia, osteoporosis, and
to closed treatment. tumors.
Dorsal plating buttresses the fracture to correct deformity
and maintain fracture reduction. Positioning
New intramedullary implants have been designed to alle- • The patient is placed supine on a regular operating table.
viate some of the complications associated with traditional • A tourniquet is placed near the axilla with the splint in place.

A B c D
FIG :J • PA radiograph (A,} and lateral radiograph (B) of a healed distal radius fracture fixed with an intramedullary plate. C:,D. PA and
lateral radiographs showing an unstable metaphyseal distal radius fracture. (C:.D: copyright Thomas R. Hunt Ill, MD.)
109 -

• Afur anesthesia has been administered. the arm is placed on

a radiolucent hand table (FIG 4 ).
• Motion of the shoulder and elbow should be adequate to
allow adequate reduction and positioning.
• Image intensification using fluoroscopy should be per-
fanned throughout the procedure to assess fracture reduction
and the position of the hardware.
• The dorsal approach to the distal radius through the third
dorsal compartment with subperiosteal elevation of the com-
partments provides the exposure needed to place a dorsal plate
while protecting the extensor tendons from the plate and screws.
This approach helps to minimize adhesions and the risk of
tenosynovitis and tendon rupture.
• The approach used to place an intramedullary device de-
pends on the nature of the implant and the location and extent
of the fracture.
Dorsal intramedullary implants are placed through a FIG 4 • Patient is positioned supine with arm on a hand table
limited dorsal approach through the third extensor and tourniquet applied on proximal arm.
Radial intramedullary implants are placed through a
small radial incision with careful protection of the radial
sensory nerve.


Incision and Dissection • The EPL tendon can then be removed from the third
compartment and protected for the rest of the surgical
• The skin incision is centered over the tubercle of Lister
• The subcutaneous tissues are dissected down to extensor
• The extensor compartments are subperiosteally elevated
using a scalpel in radial and ulnar directions to expose
retinaculum, with care to preserve any sensory nerve
the dorsal cortex of the distal radius (IECH FIG 1E.F).
branches while obtaining hemostasis with bipolar elec-
• If properly maintained, the periosteum of the exten-
trocautery (IECH FIG 11).
sor compartments can be repaired after placement of
• The extensor retinaculum is incised just ulnar to the tu-
bercle of Lister, exposing the extensor pollicis longus
the fiXation device and will serve as a barrier between
the dorsal plate and the extensor tendons.
(EPL} tendon (IECH FIG 1C).
• The hematoma is evacuated and the EPL tendon is freed
• The tubercle of Lister is almost invariably involved in the
fracture and should be completely removed using a
proximally and distally by incising the septa of the third
rongeur (IECH FIG 1G).
compartment (IECH RG 1D).

I c
TECH FIG 1 • A. Skin incision is drawn in relation to the tubercle ofLister. B. Skin incision is carried down to extensor reti-
naculum. Tubercle of Lister and retinacular incision are drawn. C. The retinaculum is incised and the EPL tendon is exposed.
Hematoma has already been evacuated. (continued)

Extensor pollleis

D E &lbperiosteal di~ian of 2nd and 41h companmern

TEat FIG 1 • (continued) D. Elq)osing EPl by

incising the septa of the third dorsal com-
partment. E. Subperiosteal elevation of
the second and fourth dorsal compartments.
F. Diagram demonstrating Ute transposition
of EPL and dissection deep to the extensor
compartments. G. Removal of tubercle of
Lister. H. Exposing the radial shaft with a pe-
H riosteal elevator.

• The radius shaft is exposed with a periosteal elevator • Kirschner wires can be used for temporary foortion.
(IEat RG 1H). • Bone graft is inserted to support reduced articular
Reduction and Plate Fixation • The dorsal plate is applied directly on the radius (IEat
• Reduction is obtained and confirmed using axial FIG 21).
traction and palmar translation of the hand (TEat
FIG 2A).
• The plate is secured beginning with a bicortical screw in
the oval sliding hole.
• If reduction of articular fragments is needed, the radial • Fracture reduction and placement of the plate are co~
portion of the origin of the dorsal radiocarpal ligament firmed using fluoroscopy.
can be elevated sharply off the radius to evaluate the ar- • The plate is secured to the distal fragment with one or
ticular surfaces. two cancellous screws. The surgeon should avoid placing

TEat FIG 2 • A. Reduction maneuver. The distal radius is reduced over

a bump of towels using traction and pal mar displacement of the carpus.
B. Plate placement. The plate is placed deep to the EPL and aligned dis-
tally over the distal radius. C,D. Reduction imaging. c. PA fluoroscopic
view demonstrating final reduction with well-aligned plate. D. Lateral
fluoroscopic view demonstrating final reduction with appropriate-
length screws and good distal buttressing of the fracture. Volar tilt has
B been restored.
the distal, ulnar screw if possible as this may irritate the
overlying digital extensor tendons in the fourth dorsal
• Additional cortical screws are added in the radius shaft.
• Reduction and stability are confirmed (IECH RG 2C.D).

Wound Closure
• The wound is copiously irrigated.
• The retinaculum is closed deep to the transposed EPL
tendon, incorporating the periosteal layer that forms the
floor of the extensor compartments (IEat RG 3A). A
• The skin is closed with nylon suture (IEat FIG 38}.
• A volar splint is applied.

1Eat RG 3 • A. Retinacular closure. The extensor retinaculum

is closed deep to the EPl with a nonabsorbable suture. B. Skin
closure. The skin is closed with a horizontal mattress stitch to
evert the skin edges. B


• The fracture is exposed using a limited version of the • The tubercle of Lister is removed and an awl is used to
incision detailed for placement of a dorsal plate (IECH create an entry point in the dorsal cortex ClEat FIG 48).
FIG4A). • This usually involves a portion of the fracture line.
• The extensor retinaculum is incised just ulnar to the • The canal is rasped until the rasp may be fully seated
tubercle of Uster, exposing the EPl tendon. (IECH RG 4().
• The EPL tendon is freed proximally and distally by in- • The implant is placed using the insertion device to con-
cising the septa of the third compartment. trol rotation (IECH RG 4D).
• The EPL tendon can then be transposed for the rest of • Fracture reduction is typically achieved as the device
the surgical procedure. is inserted and seated due to its buttress effect and
• A scalpel is used to subperiosteally elevate the fourth three-point fixation in the canal.
and portions of the second extensor compartment in ra- • Lag screws are inserted as required, followed by a cover
dial and ulnar directions. lock to create fixed angle stability.
• The dorsal cortex of the distal radius is exposed and • Reduction and stabilization are confirmed radiographi-
room is created for seating of the extramedullary por- cally (IEat FIG 4E.F}.
tion of the device. • Wound closure and splinting are as described above.

1Eat FIG 4 • A. A 2.5-cm dorsal incision is used for exposure. B. The awl is inserted Utrough
the fracture site after removal of the tubercle of Lister. (continued)

'IEat FIG 4 • (continued) C. A rasp is used to create a path
for the implant. D. The implant is placed using the insertion
device so as to control rotation during seating. E,.F. An un-
stable metaphyseal distal radius fracture has been reduced
and stabilized using a dorsal intramedullary device (Tornier
D Corp). (E,.F: copyright Thomas R. Hunt Ill, MD.)


• A 2- to 3-cm incision is made over the radial styloicl. be- • The proximal interlocking screws are then placed using
tween the first and second extensor compartments. the insertion jig, using small incisions of the dorsal aspect
• care is taken to protect branches of the radial sensory of the forearm.
nerve. • The distal interlocking screws are placed last using the i~
• A cannulated drill is used to penetrate the cortex 2 to sertion jig.
3 mm proximal to the radiocarpal joint line to create the • Small adjustments to radial height and tilt can be
entry point. made at this time.
• After insertion of a starter awl, the canal is broached se- • Reduction and stabilization are confirmed radiographi-
quentially under fluoroscopic guidance to fit the cally.
medullary canal. • Wound closure and splinting are as described above.
• The implant is then inserted with the insertion jig, mak-
ing sure the implant is countersunk into the radial styloid.


Indications • Determine the direction of fracture stability.
• Determine the area and extent of comminution.
• Ensure that an acute carpal tunnel syndrome does not exist.
Surgical approach • Incise the extensor retinaculum sharply to allow easier repair.
• Expose only the third dorsal compartment.
• Remove the tubercle of Lister to allow better plate contouring.
Hardware choice • Choose a low-profile implant system that offers the flexibility needed to stabilize the fracture.
and placement • Place the plate distally to ensure buttress effect.
• Place the oval plate hole screw initially.
• Do not place the plate distal to the dorsal lip of the distal radius.
• Avoid placing the distal, ulnar screw.
• Although titanium implants and their particulate debris have been implicated in the development of
tenosynovitis and other tendon pathology, there is no clear scientific evidence to substantiate these claims.
Postoperative • Avoid casting for long periods.
management • Encourage early active range of motion of the wrist and fingers.
• Avoid using a sling to prevent unnecessary shoulder and elbow stiffness.
• Do not begin strengthening until range of motion is restored.

POSTOPERATIVE CARE • Malunion or nonunion

• Compartment syndrome
• Postoperativdy the patient is pla~ed in a bulky dressing that
• Carpal tunnd syndrome
allows motion of the digits, dbow, and shoulder. A volar rest-
• Late tendon rupture, potentially related to implant design
ing splint may be used to support the wrist if there is any ~on­
and material
~em about fixation strength.
• Hardware failure
• The patient is enrouraged to begin finger range-of-motion
• Complex regional pain syndrome type I
exercises immediatdy after surgery.
• Seven to 10 days after surgery the sutures are removed, DISCLOSURE
Steri-Strips are applied, and the incision is allowed to get wet.
Dr. Beredjiklian is a sto~kholder with and ronsultant for
• The patient is evaluated by an o~upational therapist, who
provides a thermoplasti~ splint, and ~an start a~tive and a~­ T ornier, In~.
tive-assisted range-of-motion exercises depending on fra~ture
stability. REFERENCES
• When the fra~ture heals at about 6 weeks, gentle passive 1. Glowacki KA, Weiss AP, Akdman E. Distal radius fractures: con-
range of motion and strengthening may be started. cepts and complications. Orthopedics 1996;19:601~08.
2. Grewal R, Perey B, Wilmink M, Stothers K. A randomized prospec-
tive study on the treatment of intra-articular distal radius fractures:
OUTCOMES open reduction and internal fixation with dorsal plating versus mini
• Dorsal plating has re~ently been shown biome~hanically to open reduction, percutaneous fixation, and external fixation. J Hand
be stronger and stiffer than volar plating for dorsally unstable Surg Am 2005;30A:764-772.
fractures. 12 3. Jupiter JB, Fernandez DL. Comparative classification for fractures of
the distal end of the radius. J. Hand Surg Am 1997;22A:563-571.
• Dorsal plating has been associated with a higher ~omplica­
4. Kamath AF, Zurakowski D, Day CS. Low-profile dorsal plating for
tion rate than other means of stabilization.2,9 •10 dol'llally angulated distal radius fractures: an outcomes study. J Hand
Extensor tenosynovitis and tendon rupture have been Surg Am 2006;31A:1061-1067.
prevalent in the past, mainly due to bulky implants. 5. Katz MA, Beredjiklian PK, Bozentka DJ, et al. Computed tomogra-
• There has been renewed interest in dorsal plating of the dis- phy scanning of intra-articular distal radius fractures: does it influ-
tal radius as it has been shown to have a low rate of tendon- ence treatment? J Hand Surg Am 2001;26A:412-421.
rdated ~omplications with the use of low-profile, anatomic 6. Knirk JL, Jupiter JB. Intra-articular fractures of the distal end of the
radius in young adults. J Bone Joint Surg am 1986;68A:647-659.
implants. 4 •10•11
7. Lafontaine M, Hardy D, Dclince P. Stability assessment of distal ra-
• Clinical reports have suggested that low-profile systems are dial fractures. Injury 1989;20:208-210.
more important in satisfa~tory ou~omes for dorsal plating, 8. Mackenney PJ, McQueen MM, Elton R. Prediction of instability in
with a mu~h lower rate of rompli~ations. 10 distal radial fractures. J Bone Joint Surg Am 2006;88A:1944-1951.
• Fixation with low-profile dorsal plates ~an result in at least 9. Nana AD, Joshi A, Lichtman DM. Plating of the distal radius. JAm
80% of contralateral wrist range of motion, about 80% to Acad Orthop Surg 2005;13:159-171.
10. RozentallD, Beredjiklian PK, Bozentka DJ. Functional outcome and
90% of grip strength, and over 90% pind strength, with min-
complications following two types of dorsal plating for unstable frac-
imal risk of tendon rupture.4•11 tures of the distal part of the radius. J Bone Joint Surg Am 2003;85A:
COMPLICATIONS 11. Simic PM, Robison J, Gardner MJ, et al. Treatment of distal radius
• Infection (pin tra~t or deep) fractures with a low-profile dorsal plating system: an outcomes as-
sessment. Hand Surg Am 2006;31A:382-386.
• Injury to tendons, vessds, and nerves
12. Trease C, Mclff T, Toby EB. Locking versus nonlocking T-plates for
• Stiffness dol'llal and volar fixation of dorsally comminuted distal radius frac-
• Posttraumati~ arthritis tures: a biomechanical study. Hand Surg Am 2005;30A:756-763.
• Weakness in grip or pind 13. Trumble TE, Culp R, Hanel DP, et al. Intra-articular fractures of the
• Tenosynovitis and tendon ruptures distal aspect of the radius. J Bone Joint Surg Am 1998;80A:582~00.
- Volar Plating of Distal
Chapter 12 Radius Fractures
t John J. Fernandez

DEFINfTION It is the .floor of the fibro-osseous extensor tendon com-

partments and includes Lister's tubercle, assisting in exten-
• Distal radius £ractuJ:e8 are defined by their involvement of
sor pollicis longus function (FIG 1A).
the metaphysis of the distal radius.
The extensor tendons are in immediate contact with the
• They are assessed on the basis of fracture pattern, align-
dorsal surface of the distal radius.
ment, and stability:
• Volarly
Articular versus nonarticular
The distal radius is the origin for the extrinsic ligaments
Reducible versus irreducible
of the carpus, including the radioscaphocapitate ligament.
Stable versus unstable
It also is the origin of the pronator quadratus.
• Irreducible or unstable fractures require surgical reduction
The flexor tendons are separated from the distal radius by
and stable fixation.
the pronator quadratus.
• Volar plating historically has been the method of choice for
• Ulnarly
volar shear-type fractures.
The distal radius is the origin for the radial triangular
R.ecendy developed fixed-angle plates have now made it a
fibrocartilage (FIG 1A).
preferred method of .fixation for most types of distal radius
It also contains the sigmoid notch, which articulates with
the head of the distal ulna, contributing to forearm rotation.
• Distally
ANATOMY The surface is divided into a triangular, radioscaphoid
• The distal radius serves as a buttress for the proximal car- fossa and a square, radiolunate fossa articulating with the
pus, transmitting 75% to 80% of its forces into the forearm. respective carpal bones (FIG 1B).
The remaining 20% to 25% of force is transmitted • The distal articular surface is inclined approximately 22 de-
through the distal ulna and the triangular fibrocartilage grees ulnarly in the coronal plane and 11 degrees volarly in the
complex (TFCC). sagittal plane (FIG 1C.D).
• Dorsally • The metaphysis is defined by the distal radius within a
The distal radius is the origin for the dorsal radiocarpal length of the articular surface that is equivalent to the widest
ligament. portion of the entire wrist.

A B c

FIG 1 • A. Axial MR image of the wrist at the level of the distal radius. Lister's tubercle is
marked with an asterisk. Dotted lines represent dorsal and volar borders of the triangular
fibrocartilage that helps stabilize the distal radioulnar joint. The dorsal distal radius acts as
an attachment for dorsal extensor compartment sheaths. B. The distal articular surface of
the radius is divided into a triangularly shaped scaphoid fossa (SF} and a square-shaped
lunate fossa (Lf). The distal ulna and the triangular fibrocartilage complex (TFCQ act as
ulnar buttresses for the wrist. C. MR coronal cut of the distal radius. The articular surface
of the distal radius is inclined about 22 degrees relative to the forearm axis (dotted lines).
The ulnar aspect of the distal radius (ie, the lunate fossa) usually is distal to the end of the
distal ulna (ie, negative ulnar variance). Note the solid lines marking ulnar variance. D. MR
sagittal cut of the distal radius. The articular surface of the distal radius is inclined
approximately 11 degrees palmar relative to the forearm axis (dotted lines}. Proximally,
D there exists relatively thinner dorsal cortical bone versus the thicker volar bone.

115 -

• The dorsal cortical bone is less substantial than the volar • As wrist defo.rmity increases, physiologic function is pro·
cortical bone, contributing to the characteristic dorsal-bending gressively altered.
fracture pattern of distal radius fractures. Intra-articular displacement of 1 to 2 mm results in an
increased risk of osteoarthritis.3•6
PATHOGENESIS Radial shortening of 3 to 5 mm or more results in in-
• The mechanism of injury in a distal radius fracture is an creased loading of the ulnar complex.1•12
axial force across the wrist, with the pattern of injury deter- Dorsal angulation greater than 10 degrees shifts contact
mined by bone density, the position of the wrist, and the mag- forces to the dorsal scaphoid fossa and the ulnar complex,
nitude and direction of force. causing increased disability.13•16
• Most distal radius fractures result from falls with the wrist • The incidence of associated intracarpal injuries increases
extended and pronated, which places a dorsal bending mo- with fracture severity. Such injuries can account for poor
ment across the distal radius. outcomes. These injuries often are not recognized at first,
Relatively weaker, thinner dorsal bone collapses under with the result that treatment is delayed.4 •14
compression, whereas stronger volar bone fails under tension, Triangular fibrocartilage (lFC) tears
resulting in a characteristic "triangle" of bane comminution Scapholunate and lunotriquetralligament tears
with the apex volar and greater comminution dorsal. Chondral injuries involving the carpal surfaces
• Other possible mechanisms form a basis for some fracture Distal radioulnar joint injury
classifications such as the one proposed by Jupiter and Distal ulna fractures
Femandez.5 • By predicting the stability of a distal radius fracture, defor·
Bending mity and its complications can be minimized. Several risk
Compression factors have been suggested by LaFontaine et al7 and others.
Shear The presence of three or more indicates instability:
Avulsion Dorsal angulation greater than 20 degrees
Combinations Dorsal comminution
• Articular involvement and its severity are the basis of some Intra-articular extension
fracture classifications, such as the A09 and Melone8 Associated ulna fracture
classifications. Patient age over 60 years
• Articular involvement splits the distal radius into distinct
fragments separate from the radius shaft (FIG 2 ): PATIENT InSTORY AND PHYSICAL
Scaphoid fossa fragment FINDINGS
Lunate fossa fragment. Further comminution can split the • The mechanism of injury should be sought, to assist in as·
lunate fossa fragment into dorsal and volar segments, creat- sessing the energy and level of destruction.
ing the so-called four-part fracture. • Associated injuries are not uncommon and should be care·
fully ruled out.
NATURAL InSTORY Injuries to the hand, carpus, and proximal arm, including
• Clinical outcome usually, but not always, correlates with other fractures or dislocations
defo.rmity. Injuries to other extremities or the head, neck, and torso
Variable residual deformity can be tolerated best by indi- • Establish the patient's functional and occupational demands.
viduals with fewer functional demands. • Document co-existing medical conditions that may affect
healing, such as osteoporosis or diabetes.
• Determine possible risk factors for anesthesia and surgery,
such as cardiac disease.
• The physical examination should document the following:
Condition of surrounding soft tissues (ie, skin and subcu-
taneous tissues)
Quality of vascular perfusion and pulses
Integrity of nerve function
Sensory two-point discrimination or threshold sensory
Motor function of intrinsic, thenar, and hypothenar mus·
des of the hand
• Examination of the distal ulna, lFCC, and distal radioulnar
joint should rule out disruption and instability.
• Reliable physical examination of the carpus often is difficult,
making radiographic review even more critical and follow-up
e:xaminations important.

FIG Z • The arrowhead points to the articular split. Articular

displacement of the scaphoid fossa fragment radially and the STUDIES
lunate fossa fragment ulnarly is apparent, as is significant • Imaging establishes fracture severity, helps determine stabil-
shortening (ulnar positive variance) as outlined by the lines. ity, and guides the operative approach and choice of fixation.

A 8 c
RG J • A. This pronated view
accentuates the dorsal articular sur-
face irregularity (atTOwhead) and
the displaced fragment. a. This
supinated view accentuates the dis-
placed radial styloid fragment. C. On
this lateral radiograph, the arrow-
head paints to the articular split and
the displacement of the lunate fossa
fragment. Note the dorsal angula-
tion and collapse (dotted line).
Observe the significan-tfy thicker
volar cortical bane in comparison to
the dorsal bane. D,E. AP and lateral
cuts taken from cr images of a distal
radius fracture revealing the extent
of comminution and central im-
paction. which are not easily
D E appreciated an plain radiographs.

• Plain radiographs should be obtained before and after re- NONOPERATIVE MANAGEMENT
duction: PA, lateral, and two separate oblique views.
• Nonoperative treatment is reserved for distal radius frac-
Oblique views, in particular, help evaluate articular in-
tures that are reducible and stable based on the criteria previ-
volvement, particularly the lunate fossa fragment (FIG 3A.B).
ously discussed.
The lateral view should be modified with the forearm in-
• The goal of nonoperative treatment is to immobilize the
clined 15 to 20 degrees to best visualize the articular surface
wrist using a method that will maintain acceptable alignment
(FIG 3C; see Tech Fig SBC).
until the fracture is healed.
• FluoroSCQpic evaluation can be useful, because it gives a
Radial inclination greater than 10 degrees
complete circumferential view of the wrist and, with traction
Ulnar variance less than 4 mm positive
applied, can help evaluate injuries of the carpus.
Palmar tilt less than 15 degrees dorsal or 20 degrees volar
• cr helps define intra-articular involvement and helps detect Articular c.oogruity less than 2-mm gap or step-off
small or impacted fragments, which may not be apparent on
plain radiographs, particularly those involving the central por-
tion of the distal radius (FIG 3D,E). SURGICAL MANAGEMENT
• The goal of operative treatment is to achieve acceptable
DIFFERENTIAL DIAGNOSIS alignment and stable fixation.
• Diagnosis is directly confirmed by radiographs. • Various methods of fixation are available: pins, external fix-
• Associated and contributory injuries should always be ators, dorsal plates, intramedullary devices, and volar plates.
Pathologic fracture (eg, related to tumor, infection) Preoperative Planning
Associated injuries to the carpus (eg, scaphoid fracture, • The standard preoperative medical and anesthesia evalua-
scapholunate ligament injury) tion for concurrent medical problems is done.
117 -

• Discontinue blood thinning medications (anticoagulants • Incorporate weights or a ttaction system to apply disttaction
and nonsteroidal anti-inflammatory drugs). across the fracture (FIG 4 ).
• Request necessary equipment, including fluoroscopic and • The surgeon is seated on the side, toward the patient's head,
power equipment. particularly if he or she is right-hand dominant.
• Confirm the plate fixation system to be used and check the • The assistant is seated opposite the surgeon.
equipment before beginning surgery for completeness (ie, all • The fluoroscopy Wlit is brought in from the end or corner of
appropriate drills, plates, and screws). the table.
• Have a contingency plan or additional fixation (external fix-
ator, bone graft, or bone graft substitute). Approach
• Review previous radiographic studies. • Dorsal exposure allows for direct visualization of the artic-
• Consider use of a regional anesthetic for postoperative pain ular surface when necessary.
control. • Fracture comminution is more severe dorsally, making over·
all alignment more difficult to judge.
Positioning • The thicker volar cortex is less comminuted, allowing for
• Place the patient in the supine position with the affected ex- more precise reduction and buttressing of bone fragments.
tremity on an arm table. • Sometimes both dorsal and volar exposures may be neces-
• Apply an upper arm tourniquet, preferably within the ster- sary to achieve articular congruency and volar reduction and
ile .field. fixation, respectively.
• An extended vofa.r:.-ulnar exposure may be ne«ssary to per·
form a carpal tunnel release if indicated.
• The techniques described in this chapter use the volar ap-
proach to distal radius, as described by Henry (FIG 5).

FIG 4 • Traction is applied over the arm table with finger traps FIG 5 • The volar incision is represented by the dotted line just
and hanging weights. The surgeon sits on the volar side, and proximal to the wrist flexion creases and radial to the flexor
the assistant on the dorsal side. Fluoroscopy can be brought in carpi radialis longus. Care is exercised to avoid dissection ulnar
from any direction. but preferably from the side adjacent or the to the flexor carpi radialis, because the palmar cutaneous nerve
opposite surgeon. branch of the median nerve (arrow} is at risk.


Incision and Dissection • Incise the anterior sheath of the flexor carpi radialis ten-
• Palpate the flexor carpi radialis tendon and make a 4- to don and retract the tendon ulnarly to help protect the
8-cm longitudinal incision from the proximal wrist flex- median nerve (IECH FIG 11).
ion crease, extending proximally along the radial border
of the flexor carpi radialis tendon.
• Incise the posterior sheath of the flexor carpi radialis
• If the incision must cross the wrist flexion creases, use • The deep tissues likely will bulge out from the pres-
a zigzag incision in that area. sure of swelling and fracture hematoma.
• carefully avoid the palmar cutaneous branch of the me- • The median nerve lies within the subcutaneous
dian nerve along the ulnar side of the flexor carpi radi- tissues along the ulnar portion of the wound
alis within 10 em of the wrist flexion crease. (IECH FIG 1C:,D).
• Branches of the dorsal radial sensory nerve and lateral • The flexor pollicis longus tendon sits along the radial
antebrachial cutaneous nerve sometimes appear along margin of the wound.
the path of the incision and also need to be protected. • Using blunt dissection with a gauze-covered finger,
• At the distal end of the incision, protect the palmar sweep the tendons and the nerve ulnarly.
branch of the radial artery to the deep arch. • A self-retaining retractor is carefully placed between
• It usually is not necessary to dissect out the radial the radial artery radially and the tendons and median
artery (IEat RG 1A). nerve ulnarly.


c D


TEat FIG 1 • A. The interval between the radial artery (an-ow) and the flexor carpi radialis tendon
(*} is seen. B. The posterior sheath (*} of the flexor carpi radial is is visible after retracting the flexor
carpi radialis ulnarly (arrow). Be careful during deeper dissection, because swelling and hematoma
may distort the position of the median nerve beneath the sheath. C. Following incision in the flexor
carpi radialis posterior sheath, the deep tendons are visible, including the flexor pollicis longus (FPL,)
and the flexor digitorum superficialis of the index finger (FDS}. The median nerve also is visible (*}.
D. The palmar cutaneous nerve branches of the median nerve (arrow) and median nerve (asterisk)
are both at risk for injury during this approach. Be careful regarding placement of retractors and
during dissection and plate placement. E. The pronator quadratus (PQ} is incised distally, radially,
and proximally and then reflected ulnarly after dissection off the volar distal radius. F. The brachia-
radialis (an-ow) can be a deforming force, especially in comminuted fractures and in those for which
treatment has been delayed. This tendon can be released if necessary.

• The pronator quadratus is now visualized at the floor • The radial margin is in proximity to the tendons
of the wound. of the first dorsal compartment and the brachi~
• Incise the pronator quadratus at its radial insertion, leav- radialis.
ing fascial tissue on either side to aid in closure. Also, de- • Subperiosteally dissect the pronator quadratus off the
termine the proximal and distal extent of the muscle, volar surface of the distal radius as an ulnarly based flap
and make horizontal incisions at both of those points with a knife or elevator.
(IEat RG 1E). • Retract the pronator ulnarly with the flexor tendons and
• The distal margin of the pronator quadratus attaches median nerve.
along the distal volar lip of the distal radius, along • Particularly if significant shortening of radial-sided frac-
the ...teardrop .... ture fragments has occurred, incise the broad insertion
of the brachioradialis to eliminate the deforming force
(IEat FIG 1F}.
• Carefully clean the fracture of any interposed muscle,
fascia, hematoma, or callus while maintaining the bony
• Release the first dorsal compartment and retract the contours.
tendons before releasing the brachioradialis. • In the case of significant volar comminution, reduce and
• Alternatively, Z-lengthen the brachioradialis tendon provisionally stabilize the fragments with K-wires.
to allow for repair at the completion of the case. • Take plate positioning into account when placing
these K-wires.
Fracture Redudion and • The articular surface is first reduced, if necessary.
Provisional Fixation • Under fluoroscopic guidance, manipulate the articular
• Apply a lobster-claw damp around the radius shaft at a fragments through the fracture with a periosteal eleva-
perpendicular angle to the volar surface at the most tor, osteotome, or K-wires (IEat FIG 2B,C).
proximal portion of the wound (IEat FIG 2A). • Longitudinal traction is important during this reduc-
• This allows for excellent control of the proximal shaft tion phase. It can be performed by an assistant or
for rotation and translation. using cross-table weights and finger-traps.
• It also provides an excellent counterforce when cor- • A dorsal exposure is performed at this stage if there is
recting the dorsal angulation collapse. significant impaction, particularly centrally, that can-
• With the fracture now exposed, apply traction distally to not be corrected using the extra-articular technique
distract and disimpact the fragments. described here.


1Eat FIG 2 • A. A lobster-claw clamp (double artow} is applied to the radius shaft well
proximal to the fracture. This instrument helps the surgeon control the radius during
reduction and define the lateral margins of the radius. A Freer elevator is inserted into
the fracture to help disimpact the fragments and assist in their reduction. B. The bra-
chioradialis (white artow) is released, and the first compartment extensor tendons are
visible in the background (black artow). An instrument can now be placed to assist in
the reduction (anow}. C. The Freer elevator is used to reduce the fragments. In this
case, the intriHirticular step-off is being corrected, and the radial length and inclina-
tion are being restored. D. K-wires are placed across the radial styloid into the reduced
ulna fossa fragment. An assistant usually applies traction, and the lobster-daw clamp
can be used for powerful leverage. If there is no articular involvement. this K-wire can
be placed into the radius metaphysis or diaphysis proximally. E. The K-wire should
be placed as close as possible to the subchondral bone, avoiding areas of comminution.
c F. The K-wire should maintain the articular reduction without any support.

• Place K-wires from the radial styloid fragment into the • The K-wires allow for fine adjustment in plate posi-
lunate fossa fragment to maintain the articular reduc- tion before committing to insertion of a screw.
tion (IEat FIG 2D). • Drill and insert a provisional screw in the oblong hole in
• The K-wires should be placed as close as possible to the plate.
the subchondral plate (IEat FIG 2E,F). • If the bone is osteopenie, a screw longer than the
• Once the distal articular reduction is complete, reduce initial measurement should be placed to ensure that
the distal radius as a single unit to the radius shaft. both cortices are engaged. Otherwise, the plate may
• Insert K-wires as required to maintain the provisional re- not be held securely, and the reduction will be com-
duction between the distal fragments and the proximal promised. After the remaining screws have been
shaft fragment. secured, this screw can be replaced with one of the
• If radial collapse and translation are prominent. a appropriate length.
large K-wire can be introduced into the radial portion • Insert at least one additional proximal screw and remove
of the fracture and advanced proximally and ulnarly the provisional K-wires holding the plate in place.
to behave like an intrafocal pin and provide a radial
buttress by pushing the distal fragment ulnarly. Distal Fragment Reduction
• A similar technique can be applied through the dor-
• Once the proximal plate has been secured, execute any
sal fracture to assist in maintaining the palmar tilt
additional reduction needed.
• A well-designed plate serves as an excellent buttress
for correction of the palmar tilt (IEat FIG 4A).
Plate Application
• Apply counterforce through the lobster-claw damp in a
• Apply a fixed-angle volar plate to the volar surface of dorsal direction while the distal hand and wrist are trans-
the distal radius and shaft. Position the plate to accom-
lated palmarly and flexed (IEat RG 48).
modate for the unique design characteristics of the
• This maneuver reduces the distal radius to the
plating system as well as the location of the fracture
plate, effectively restoring volar tilt by pushing the
lunate againstthe volar lip of the distal radius (IEat
• Each plating system has unique characteristics that FIG 4C,.D).
determine its optimal placement. • Additional distraction and ulnar deviation correct radial
• Ideally, the plate should be placed as dose to the ar- collapse and loss of radial inclination.
ticular margin as possible without the distal locking
pegs or screws penetrating the joint.
• If the fracture has not yet been fully reduced, this
must be taken into account when placing the device.
• aamp the previously applied lobster claw to the proxi-
mal portion of the plate to keep the plate centralized on
the radius shaft.
• Place provisional K-wires through the plate to maintain
position ClEat FIG 3). Then fluoroscopically confirm
proper plate position in both the distal-proximal and ra-
dioulnar directions.
• Proper alignment of the plate can be determined
only using a true anteroposterior (AP) image in which
the distal radioulnar joint is well visualized.

1Eat FIG 4 • A. The final reduction is performed with trac-
1Eat FIG 3 • Keep the plate centered on the radius and as tion on the hand and with the radius held proximally with a
distal as possible. The lobsteHiaw clamp helps keep the clamp. Once the reduction is confirmed radiographically, the
plate centered. K-wires (arrom) are helpful as provision fix- assistant places the distal screws or K-wires. B. The hand is
ation until alignment can be confirmed radiographically and translated (not appreciably flexed) palmarly while the radius
screws placed. shaft is held with the clamp. (continued)

TECH RG 4 • (continued) Prereduction (C)

and postreduction (D) radiographs demon-
strating the palmar translation reduction
maneuver. The volar plate acts as a strong
buttress (arrow}, allowing the translated lu-
nate to push on the volar radius (*)and cor-
rect the dorsal angulation deformity.

Plate Fixation (IEat FIG 5B,C). This is facilitated by lifting the

wrist off the table with the elbow maintained on
• While the reduction is held, drill the holes in the distal the table and the forearm at a 20-degree angle to
plate (IECH RG SA). the table (IEat FIG SD,E).
• Some plate systems allow for provisional fixation • Lister's tubercle can be mistaken for the dorsal cortex,
using K-wires placed through the distal plate. resulting in screws that are too long.
• Do not penetrate the dorsal distal radius with the • The extensor pollicislongus is at greatest risk of injury
drill, to protect the dorsal extensor tendons. from a protruding screw.
• Drill and place the distal ulnar screws first and then pro- • Sequentially insert the remaining distal screws or pegs,
ceed radially and proximally. followed by the remaining proximal plate screws
• Judge the placement of all distal screws or pegs precisely ClEat FIG SF).
using fluoroscopic imaging in multiple planes. • If necessary, add bone graft or bone graft substitute
• Perform a •true" lateral view of the wrist with the around the plate into the fracture site or through a small
x-ray beam at a 20-degree angle to the radius shaft dorsal incision.

B C ' - - -- -
'IEat FIG 5 • A. The remaining holes can now be drilled and screws
placed where needed. B. This screw (am:~w) looks as 1hough it has pen-
etrated the joint when in reality it is simply 1he angle of the radi-
ographic beam that throws its projection into the joint. C. A true lateral
view of the distal radius is necessary to judge placement of the radial
screws. D. A radiograph is being taken with the wrist perpendicular to
the x-ray beam (arrow}. This is not a true lateral image, because the dis-
D tal surface of the radius is inclined 20 degrees radially. (continued)


TEat FIG 5 • (continued) E. By lifting the hand and wrist 20 degrees off the table, a "true" lateral
image can be achieved. The x-ray beam is now perpendicular to the joint (arrow}. F. The remaining
screws have been placed.

• Precisely assess the stability of the construct after the • Before skin closure, obtain final radiographs (IEat FIG
plate has been applied. If appropriate, remove the provi- IB,C), and assess stability of the distal radioulnar joint.
sional K-wires. • Place a drain only if excessive bleeding is anticipated.
• If the K-wires are deemed critical for fracture stability,
they can be left in place and removed 4 to 8 weeks later
• Consider methods to minimize postoperative pain:
• Percutaneous placement of a pain pump catheter
• If residual instability exists, add additional fixation • Injection of a long-acting local anesthetic
with K-wires, an external fixator, a dorsal plate, or a • Close the subcutaneous tissues with 4-0 absorbable su-
combination. ture and reapproximate the skin with interrupted 4-0 or
5..() nylon sutures or a running subcuticular stitch.
Closure • Place two layers of gauze and a nonadherent gauze
• Repair the pronator quadratus to its insertion site with a over the wound, wrap the wrist and forearm with
series of 3·0 absorbable horizontal mattress sutures thick Webril (Kendall, Mansfield, MA), and apply a
(IEat RG lA). below-elbow splint in a neutral wrist position ClEat
• In many cases it is impossible to repair the pronator FIG ID).
quadratus because the muscle and fasda are extremely • If there is injury to the ulnar wrist (eg, ulna styloid
thin or the musde is damaged. In this situation, the fracture, distal radioulnar joint injury}, immobilize
muscle can be debrided or simply left in place. the forearm with an above-elbow or Munster splint.

TEat FIG 6 • A. The pronator quadratus has been repaired. B. AP radi-

ograph demonstrating correction of the articular surface, radial height
(lines}, and radial inclination (dotted line}. C. Lateral radiograph demonstrat-
ing correction of the palmar tilt (dotted line). D. A bulky dressing is applied
with a volar splint holding the wrist in a neutral position. A pain pump
D catheter has been inserted for additional pain control.
• We do not recommend use of the volar fixed-angle plate • Affix the plate to the distal fragment, accounting for
as a reduction tool in the acute setting. It is best em- where the plate will sit on the radius shaft once the re-
ployed (if at all) for a malunion. or perhaps for a fracture duction is completed.
with minimal articular comminution. • Place the screws so that they are parallel to the articular
• This technique is difficult, because it has to ac- surface on the lateral x-ray view (IECH FIG7A,B) .
count for the longitudinal and translational align- • On the AP radiograph, align the plate with the perpen-
ment of the plate before the reduction has been dicular of the radial inclination of the distal radius (20
achieved. degrees; 1Eat RG 7C:::,D}.
• Perform the surgical approach previously described. • Once distal fiXation is complete, secure the proximal plate
• Address first any distal articular involvement with reduc- to the radius shaft, thereby completing the reduction.
tion and K-wire fixation. • aose and splint as described previously.

TEat FIG 7 • A. The volar plate is applied with the distal screws
placed first (parallel to distal articular surface). B. Reducing the plate
to the diaphysis proximally accomplishes the reduction. C. The plate is
applied at approximately a 20-degree angle relative to the distal ar-
ticular surface or to the amount of angulation that is estimated. D. By
reducing the plate to the diaphysis, the distal angulation is corrected. D


Preoperative planning • Obtain multiple radiographs in different positions (eg, several oblique views}, especially in the setting
of comminution or articular involvement.
• Obtain aCT scan if assessing the pattern of fracture when radiographs alone are difficult or uncertain.
Surgical approach • Avoid crossing the distal flexion creases of the wrist.
• Avoid exposure ulnar to the midline of the flexor carpi radialis.
• Use extra care with deep dissection in the presence of hematoma or significant swelling.
Fracture reduction • Employ traction across the wrist with a device or weights.
• Use a lobster-claw clamp on the proximal radius shaft for control of the forearm and as a reference for
the lateral margins.
• Use instruments to disimpact and reduce articular fragments through the fracture itself, either volarly,
dorsally, or both.
• Employ a temporary K-wire to stabilize the reduction before placement of the plate.
Plate alignment • Confirm appropriate radial-ulnar positioning of the proximal plate using a true AP radiograph (ie,
forearm in supination with open view of the distal radioulnar joint).

• Confirm proper distal plate position on a true lateral view (ie, forearm 20 degrees off the table).
• Place the plate as distal as possible, up to the volar tear drop of the distal radius, if possible.
• Evaluate the screws for possible joint penetration using 360-degree fluoroscopic images.
Plate fixation • Use K-wires to fix the plate provisionally to the proximal radius.
• The initial •oblong hole" screw should be slightly longer than the measured length to ensure better
initial fixation.
Postoperative • Closure of the pronator quadratus is not critical and should be reserved for more substantial muscles
with limited trauma.
• Begin immediate range of motion (ROM) to digits with edema.

POSTOPERATIVE CARE The most common sites include the dorsal wrist, when
screws have been inserted, and the radial wrist, when a plate
• The wrist is splinted in a neutral position, leaving the dig-
has been used.
its free.
It can be avoided with careful screw and plate placement
If the fracture is particularly tenuous or there is injury to
and radiographic verification of their position.
the ulnar wrist, a long-arm or Munster splint is applied.
• Nonunion and delayed union are unusual. Consider a diag-
• The patient is instructed to perform active ROM exercises
nosis of osteomyelitis or other risk factors such as smoking.
for the digits every hour and to engage in strict elevation for at
• Loss of fracture reduction and fixation can occur, and is
least 3 days.
most common in patients with osteopenic bone or commin-
It is critical to emphasize edema prevention and immedi-
uted and articular fractures.
ate ROM of the digits.
This can be avoided with frequent and early follow-up
• At 1 week postoperatively, the splint is removed and the
with repeat radiographs.
wound is examined.
If instability is suspected, the fracture can be casted.
• If swelling permits, the therapist fabricates a molded
In the operating room, if instability is suspected, addi-
Orthoplast splint (Johnson & Johnson Orthopedics, New
tional fixation should be considered (eg, external fixator,
Brunswick, NJ) to be worn at all times.
pins, bone graft).
• Active ROM exercises of the wrist are implemented 1 week
• Soft tissue complications are proportional to the energy of
the initial injury.
• At 4 to 6 weeks, putty and grip exercises are added.
• Open wounds usually can be addressed with local measures.
• At 6 to 8 weeks, the splint is discontinued, and progressive
• Significant swelling must be addressed with early and ag-
strengthening exercises are advanced.
gressive modalities. Swelling can lead to other complications,
• If necessary, progressive passive ROM can begin, including
such as joint stiffness and tendon adhesions.
use of dynamic splints.
• Nerve injuries can be the result of initial trauma or subse-
• At 10 to 12 weeks, the patient usually can be discharged to
quent surgical trauma.
all activities as tolerated.
Assess and document neurologic status before surgery.
Avoid further injury to nerves with careful placement of
OUTCOMES retractors.
• Overall good to excellent results can be expected in over 80% The palmar cutaneous branch of the median nerve can be
of patients with ROM, strength, and outcomes scoring. 10•11 •15•17 injured during incision and exposure.
• Studies comparing volar fixation to other forms of fixation Postoperative neuromas can cause pain and sensitivity
(eg, external fixators, pins, and dorsal plating) have revealed along scar.
similar if not superior results. Avoid the nerve with a well-placed incision radial to the
Results appear to be superior in the early recovery period, flexor carpi radialis and careful deep dissection.
with the fmal outcome yielding equivalent results among all • Postoperative swelling also can lead to median neuropathy.
fixation groups. Carpal tunnel release should be performed if there is any sus-
Some studies suggest better maintenance in overall reduc- pected compression neuropathy or if this is to be anticipated
tion compared to other forms of fixation. as a result of postoperative swelling.
• Tendon complications include adhesions and ruptures.
COMPLICATIONS • Most tendon adhesions involve the dorsal extensor tendons
• Complication rates as high as 27% have been reported. resulting in extrinsic extensor tightness.
• Complications can be categorized into those involving hard- • Flexor tendon adhesions are uncommon and involve pri-
ware, fracture, soft tissues, nerves, and tendons. 2 marily the flexor pollicis longus.
• Failures of hardware, such as plate or screw breakage, can • Tendon ruptures have been described, especially involving
occur but are rare. Usually such failures are an indication of the flexor pollicis longus and the extensor pollicis longus, as a
other problems, such as nonunion. result of plate and screw prominence, respectively.
• The hardware becomes unacceptably prominent in a minor- The distal screws must not be left prominent, and caution
ity of patients. must be applied when drilling.
This complication may become evident only after some The sagittal and coronal profiles of the plate being used
time has elapsed, as swelling of fibrous tissue subsides and must be taken into consideration-some plates are very
bone remodels. prominent and extend far radially.

REFERENCES 10. Mwgrave DS, Idler RS. Volar fixation of dorsally displaced distal
radius fractures using the 2.4-mm locking com~cssion plates. J Hand
1. Aro Hf, Koivunen T. Minoc axial shortening of the radius affects out- Surg Am 2005;30:743-749.
come of Colles' fracture treatmmt. J Hand Surg Am 1991;16:392-398. 11. Orbay JL, Fernandez DL Volar fixed-angle plate fixation for unsta-
2. Aroca R, Lutz M, ~nnerbichler A, et al. Complications following ble distal radius fractures in the dderly patient. J Hand Surg Am
in~mal fixation of unstable distal radius fracture with a palmar lock- 2004;29:96-1 02.
ing plate. J Orthop Trauma 2007;21:316-322. 12. Pogue DL, Viegas SF, Patterson RM, et al. Effects of distal radius
3. Fc:mandez JJ, Gruen GS, Herndon JH. Outcome of distal radius frac- fracture malunion on wrist joint mechanics. J Hand Surg Am 1990;
tures using the Short Form 36 health survey. Clin Orthop Relat Res 15:721-727.
1997;341:36-41. 13. Pomr M, Stockley I. Fractures of the distal radius. In~rmediate and
4. Geissler WB, Freeland AE, Savoie FH, et al.lnrracarpal soft-tissue le- end result in rdation to radiologic parameters. Clin Orthop Relat Res
sions associated with an intra-articular fracture of the distal end of 1987;220:241-252.
the radius. J Bone Joint Surg Am 1996;78:357-365. 14. Richards RS, Bennett JD, Roth JH, et al. Arthroscopic diagnosis of
5. Jupi~r JB, Fernandez DL Comparative classification for fractures of intra-articular soft tissue injw:U:s associated with distal radius frac-
the distal end of the radius. j Hand Surg Am 1997;22:563-571. tures. J Hand Surg Am 1997;22:772-776.
6. Kuirk JL, Jupiter JB. lnrra-articulat fractures of the distal end of the 15. Rozental TD, Blazar PE. Functional outcome and complications after
radius in young adults. J Bone joint Surg Am 1986;68:647-659. volar plating for dorsally displaced, unstable fractures of the distal ra-
7. LaFontaine M, Hardy D, Delince PH. Stability assessment of distal dius. J Hand Surg Am 2006;31:359-365.
radius fractures. Injury 1989;20:208-210. 16. Shon WH, Palmer AI<, Werner FW, et al. A biomechanical study of
8. Melone CP Jr. Articulat fractures of the distal radius. Orthop Clin distal radius fractures. J Hand Surg Am 1987;12:529-534.
N O£th Am 1984;15:217-236. 17. Wright TW, Horodyski M, Smith DW. Functional outcome of unsta-
9. Muller ME, Nazarian S, Koch P, et al The Comprchc:nsive Classi- ble distal radius fractures: OR.IF with a volar fixed-angle tine plate
fication of Fractures of Long Bones. New York: Springer-Verlag, 1990. versus extl:mal fixation. J Hand Surg Am 2005;30:62.9.
- Bridge Plating of Distal Radius
Chapter 13 Fractures
t Paul A Martineau, Kevin J. Malone, and Douglas P. Hanel

DEFINfTION quences include degenerative arthritis in up to 50% of pa-

tients with even minimal displacement in the young adult
• High-energy fractures of the distal aspect of the radius with
extensive co.rwn.inution of the articular surface and extension
• As surgical treatment (plating in particular) ensures more
into the diaphysis represent a major treatment challenge.
consistent correction of displacement and maintenance of re-
Standard plates and techniques may be inadequate for the
duction, there has been a trend toward operative treatment in
management of such fractures.
both the elderly and the young population.
• Before the introduction of the bridge plating technique,
treatment of these injuries was limited to cast iuuuobilization PATIENT fDSTORY AND PHYSICAL
or external fixation with or without lGrschner wire augmenta- FINDINGS
tion. Both of these methods are associated with unacceptably
high complication rates. • In the management of high-energy distal radius fractures, a
complete history should include the mechanism of injury.
ANATOMY These fractures are commonly the result of axial loading as
opposed to the bending forces, which are all low-velocity
• The articular surface of the distal radius is tilted 21 degrees
in the anteroposterior plane and 5 to 11 degre<:s in the lateral
• Examination of the soft tissue envelope of the wrist should
be performed to rule out open fractures.
• The dorsal cortex surface of the radius thickens to form the
tubercle of Lister. • Because of the high-energy nature of these fractures, patients
are at increased risk of neurovascular compromise. Careful ex-
• A central ridge divides the articular surface of the radius
amination for signs of impending compartment syndrome as
into a scaphoid facet and a lunate facet.
well as median nerve dysfunction from an acute carpal tunnel
• Because of the different areas of bone thickness and density,
syndrome should be clearly documented.
fractures tend to occur in the relatively weaker metaphyseal
• Associated injuries should be ruled out, and appropriate pa-
bone and propagate intra-articularly between the scaphoid
tient clearance according to advanced trawna life support
and lunate facets.
guidelines should be obtained.
• The degree, direction, and magnitude of applied load may
cause coronal or sagittal splits within the lunate or scaphoid IMAGING AND OTHER DIAGNOSTIC
facets. STUDIES
• Good-quality pre- and post-reduction wrist radiographs
PAlHOGENESIS should be obtained preoperatively to assess the fracture pat-
• Two subsets of patients with distal radius fractures continue tern and rule out associated injuries to the carpus or distal ra-
to represent unique treatment challenges: dioulnar joint (DRUJ).
Patients with high-energy wrist injuries with fracture ex- • Cf scans may be helpful to assess complex intra-articular
tension into the radial diaphysis distal radius fractures.
Patients with multiple injuries who require load bearing
through the injured wrist to assist with mobilization and NONOPERATIVE MANAGEMENT
nursing care • There is no acceptable nonoperative management for high-
energy couuuinuted distal radius fractures.
• Lafontaine et al13 showed that the end results of commin- SURGICAL MANAGEMENT
uted distal radius fractures treated by closed methods resem- • The use of internal distraction plating or bridge plating for
bled the prereducti.on radiographs more than any other radi- distal radius fractures was introduced by Burke and Singer.3
ographs during treatment, even when the reduction success- The technique was expanded by Ruch et al,17 who described
fully restored wrist anatomy. the use of a 12- to 16-hole 3.5-mm plate dynamic compression
• A number of studies dearly show that restoration of normal plate (DCP) (Synthes, Paoli, PA) placed in the floor of the
anatomy after distal radius fracture provides better £unc- fourth dorsal extensor compartment to span from the intact
tion.4,6-8,1~12.14 radius diaphysis to the third metacarpal.5•17
• Functional outcome scores in patients without anatomic re- • The bridge plating technique provides strong fixation and
duction are poor.4 •15 allows for distraction across impacted articular segments.
• Malunion of the distal radius has been associated with • The technique can be combined with a limited articular
pain, stiffness, weak grip strength, and carpal instability in fixation approach for fracture patterns with intra-articular
a substantial percentage of patients.8 Long-term conse- extension.

127 -

Table 1 Indications for Bridge Plating

of Distal Radius Fractures

Indication Explanation
Metadillflhyseal comminution Elctensive comminution in metadia-
of the radius physeal region is difficult to treat 'With
standard implants used for distal
radius frac:tures.
Need fur weigflt bearing through Palieflts with associated lower limb
the uppet' extremity injuries may require the need fur
early weight bearing througfl the
upper extremities.
Polytrauma Nursing care of the multiply injured
palieflt may be easier with spanning
internal fixation than with external
Augmerrtl!cl fucation In osteoporotic bone, bridge plating
can be used to augment tenuous
Carpal instability Carpal instability, particularly radio- FIG 1 • Setup for this procedure, with longitudinal traction ap-
carpal, isolated or in combination plied through finger traps and the C-arm coming in from above
with a distal radius fracture, may be or below the hand table.
held in a reduced position with the
help of spanning internal fixation.
• With the patient anesthetized and supine on the operating
table, the involved extremity is draped free and centered on a
• Bridge plating of the distal radius was further refined by radiolucent hand table.
Hanel et al.9 The authors described a variant of the bridge • Finger traps are applied to the index and middle fingers and
plating te(:hnique using 2.4-mm AO plates passed extra-artic- 4.5 kg of longitudinal traction is applied through a rope and
ularly through the second dorsal comparttnent and secured pulley system.
onto the dorsal-radial aspect of the radius diaphysis and the • A C-arm comes in from above or below the hand table
second metacarpal (Table 1). (FIG 1 ).
Preoperative Planning Approac:h
• A 22-hole 2.4-mm titanium mandibular reconstruction • Under image intensification, the dosed reduction maneuver
plate (Synthea, Paoli, PA) or a 2.4-mm stainless steel plate described by Agee1 is performed.
spe(:ificaUy designed for use as a distal radius bridge plate • Pla~ are passed extra-articularly through the second dorsal
(DRB plate, Synthes, Paoli, PA) is used for distal radius compartment and secured onto the dorsal-radial aspect of the
bridge plating. radius diaphysis and the second metacarpal.
• The mandibular r~ttuction plate is made of titanium • The interval between the extensor carpi radialis longus
and has square ends and scalloped edges and threaded holes to (ECRL) and brevis (ECRB) is developed and the diaphysis of
accept locking screws. The DRB plate that the authors cur- the radius exposed.
rendy use is made of stainless steel and bas tapered ends to fa- • The DRB plate is introduced beneath the muscle bellies of
cilitate sliding the plate within the extensor compartment; it the outcroppers extraperiosteally and advanced distally be-
also has locking screws. tween the ECRL and ECRB tendons.


• Longitudinal traction is first used to restore length and
to assess the benefit of ligamentotaxis for the restora-
tion of articular stepoff (IECH FIG 1A,B).
• Next, the hand is translated palmarly relative to the fore-
arm to restore sagittal tilt and to assess the integrity of
the volar lip of the radius (.TECH FIG 1G-F}.
• Finally, pronation of the hand relative to the forearm is
performed to correct the supination deformity.
• Once the initial reduction maneuver is completed, the
bridge plate is then applied.

TECH FIG 1 • Radiographs show an AP projection of the

wrist injury before (A) and after (B) distraction is applied.
(continued) A B

c D


TECH FIG 1 • (col7t.inued) Cinical pictures show the wrist deformity before (C) and after (D) application of the Agee re-
duction maneuver, which is a combination of longitudinal traction and volar translation of the carpus. Radiographs
show the wrist deformity before (E) and after (F) application of the Agee reduction maneuver.


• The DRB plate is superimposed on the skin from the ra- • A second incision is made just proximal to the outcro~
dial diaphysis to the distal metadiaphysis of the second per muscle bellies (abductor pollicis longus and exten-
metacarpal. The position of the plate is verified with sor pollicis brevis}, in line with ECRL and ECRB tendons.
image intensification and markings are placed on the The interval between the ECRL and ECRB is developed
skin at the level of the proximal and distal four screw and the diaphysis of the radius exposed (IECH RG
holes of the plate (TECH FIG 2A-C). 2D,E).
• The subcutaneous tissues are infiltrated with 0.25% • The DRB plate is introduced beneath the muscle bellies of
bupivacaine with epinephrine to promote hemostasis. the outcroppers extraperiosteally and advanced distally
• A 5-<:m incision is made at the base of the second between the ECRL and ECRB tendons (IECH RG :ZF}.
metacarpal and continued along the second metacarpal • Some resistance may be encountered as the plate
shaft. In the depths of this incision, the insertions of the emerges distally but can usually be easily overcome with
ECRL and ECRB are iden~fied as they pass beneath the dis- gentle manipulation of the plate (TECH FIG 2G}.
tal edge of the second dorsal wrist compartment to insert • Occasionally. the plate will not pass through the com-
on the second and third metacarpal bases respectively. partment. In these cases, a guidewire or stout suture

TECH FIG 2 • A. The plate is placed

over the forearm and hand.
Radiographs can be taken to confirm
the position of the plate. The plate
should be centered over the second
metacarpal distally and the radius
proximally. This will be along the
course of the extensor carpi radialis
longus (ECRL}. B. Outline of the
plate. C. Incisions are made over the
second metacarpal and the radius.
A B c (col7t.inued)

TEat FIG 2 • (continued) D. The ECRL and ex-

tensor carpi radialis brevis (ECRB) tendons just
proximal to the abductor pollicis longus in the
forearm. E. Development of the interval be-
tween the ECRL and ECRB tendons to gain ac-
cess to the radius shaft. F. The proximal aspect
of the plate over the radius and in between the
ECRL and ECRB. It is important to ensure that
the plate runs within the second compartment
and not superficial to the first and third com-
partment tendons. G. The plate is advanced
proximal to distal and emerges distally over the
second metacarpal. H. A third incision is marked
out just ulnar to the tubercle of Lister.!. The ex-
tensor pollicis longus tendon has been released
from its compartment, and bone graft is in-
serted through the dorsal fracture line just
H ulnar to the bridge plate.

retriever is passed along the compartment from distal dius, the proximal half of the second compartment is
to proximal. The plate is secured to the distal end of incised, and the plate is passed under direct vision.
the wire and delivered into the hand. • The third, or periarticular, incision may also be used to
• In the rare instance that these measures fail, a third in- assess the articular surface, reduce die-punch fragments,
cision is made directly over the metaphysis of the ra- and introduce bone graft (IEat RG 2H,I).


• After the bridge plate is passed, it is then secured to the • Plate alignment along the longitudinal axis of the radius
second metacarpal by placing a nonlocking fully is guaranteed by securing the most distal and most prox-
threaded 2.4-mm cortical screw through the most distal imal screw holes first.
plate hole. The proximal end of the plate is then identi- • The remaining holes are secured with fully threaded
fied in the forearm. locking screws inserted with bicortical purchase.
• If the radial length has not been restored, then the plate, • It has been our experience that as the plate is paSISed along
secured to the second metacarpal, is pushed distally until the radial diaphysis, through the second compartment and
the length is reestablished and a fully threaded 2.4-mm along the second metacarpal, extra-artia.~lar alignment,
nonlocking saew is placed in the most proximal plate radial inclination. volar ~It, and radial length are restored.
hole. By using nonlocking screws the plate is effectively • Intra-articular reduction may be further adjusted by
lagged onto the intact bone. using limited periarticular incisions to allow for direct

manipulation of articular fragments, placement of sub- rigidity is directly proportional to how close the longi-
chondral bone grafts, repair of intercarpal ligament in- tudinal fixator bar is to the bone and the fracture. A
juries, and augmentation of fracture fixation with bridge plate, resting directly against the radius proxi-
Kirschner wires and periarticular plates. mally and metacarpals distally, therefore optimizes
• Displaced volar medial fracture fragments that are not the conditions to obtain the strongest possible fixator
reduced with this technique require a separate volar i~ construct.
cision and appropriate buttress support. • A DRB plate fiXed with a minimum of three screws at ei-
• The biomechanics I stability of spanning plates is strong ther end of the plate confers significantly more stability
and predictable. Behrens et al,2 studying the rigidity of than would an external fixator used to stabilize a compa-
external fixator configurations, demonstrated that rable fracture (IECH FIG 3).18

A B c
TECH AG 3 • Final AP (A}, oblique (8}, and lateral (C) radiographic images.


• DRUJ stability is assessed after radius reconstruction. If • If however, the patient's condition does not allow the
the DRUJ is stable, the limb is immobilized in a long-arm operation to be prolonged, the ulnar head is reduced
splint with the forearm in supination for the first 10 to manually into the sigmoid notch and the ulna is trans-
14 days postoperatively. fixed to the radius with a minimum of two 1.6-mm
• If the DRUJ is unstable, and there are no contraindications Kirschner wires passed proximal to the DRUJ.
to prolonging the operation, repair or reconstruction of
DRUJ and triangular fibrocartilage complex is undertaken.


Hardware removal • At the time of hardware extraction, if a mandibular reconstruction plate was used, the screws are re-
moved and the plate is twisted axially 720 degrees to break up the soft tissue adhesions and callus that
tend to grow around and onto the scalloped edges of the titanium plate. This maneuver is not usually
required when the smooth-edged stainless steel DRB is used.
• A removable short-arm splint is worn for 2 to 3 weeks after plate removal. Hand therapy at this point
is directed at regaining motion and strength.

POSTOPERATIVE CARE eratively the platform is removed and weight bearing is al-
• Digit range-of-motion exercises start within 24 hours of lowed through the hand grip of regular crutches. Lifting and
surgery. Load bearing through the forearm and elbow is al- carrying are restricted to about 4.5 kg until fracture healing.
lowed immediately. as well as the use of a platform crutch • DRUJ stability and forearm motion are assessed 2 weeks
when the patient is physiologically stable. One month postop· after reduction. If the patient can supinate the forearm with lit-

tie effort and the DRUJ is stable, then splinting is dis~ontinued COMPLICATIONS
and axial loading through the extremity is allowed at this
• There was one do~umented hardware failure in the series in
a patient who initially refused to have the implant taken out
• If the patient has diffi~ulty maintaining supination, or if the
and ~ontinued to work in heavy manual labor for 19 months
DRUJ was re~onstru~ted a~utely, a removable long-arm splint
before the bridge plate failed.
is fabri~ated.
• In addition, there were no ~ases of ex~essive postoperative
• If the DRUJ was transfixed with Kirs~hner wires, then the
finger stiffness or reflex sympatheti~ dystrophy.
wires are removed on the third postoperative week and DRUJ
• This refle~ts the overall infrequent ~ompli~ations reported in
stability is reassessed.
the literature for bridge plating of the distal radius. In fa~t,
• Supplemental Kirs~er wires for arti~ular fixation are re-
Burke and Singe2 reported no ~ompli~ations, and Ru~h et al 17
moved 6 weeks postoperatively.
reported no hardware failures and only three patients who de-
• The DRB plate and s~rews are removed usually no earlier
veloped long fmger extensor lag of 10 to 15 degrees.
than 12 weeks after injury.

• The bridge plating te~que for distal radius fractures was 1. Agee JM. Distal radius fractures: multiplanar ligamentotaxi.s. Hand
reviewed in a retrospe~tive study ~onsisting of 62 ~onse~utive Clin 1993;9:577-585.
patients treated in this fashion.9 The series represents the se- 2. Behrens F, Johnson W. Unilateral external fixation: methods to in-
nior author's 10-year experien~e with the ~que at a Level crease and reduce frame stiffness. Clin Orthop Relat Res 1989;241:
1 trauma renter. Patients managed with bridge plating either 3. Burke EF, Singer RM. Treatment of comminuted distal radius with
for distal radius fra~tures with extensive metadiaphyseal rom- the usc of an internal distraction plate. Tech Hand Up Extrem Surg
minution or for distal radius fra~tures associated with other 1998;2:248-252.
injuries requiring weight bearing through the affected extrem- 4. Drobetz H, Bryant AL, Pokorny T, et al. Volar fixed-angle plating of
ity represented 13% of distal radius fra~tures treated with op- distal radius extension fractures: influence of plate position on
erative fixation during this period. Fra~ture healing o~urred secondary loss of reduction: a biomechanic study in a cadaveric
model. J Hand Surg Am 2006;31A:615-622.
in all 62 patients. 5. Ginn TA, Ruch DS, Yang CC, et al. Use of a distraction plate for dis-
In ead ~ase radial length was within 5 mm of neutral tal radial fractures with metaphyseal and diaphyseal comminution: sur-
ulnar varian~e, radial inclination was greater than 5 degrees, gical technique. J Bone Joint Surg Am 2006;88A(Suppl1 Pt 1):29-36.
and palmar tilt was at least neutral. 6. Grad! G, Jupiter JB, Gicrer P, et al Fractures of the distal radius
There were also no arti~ular gaps or stepoffs greater than treated with a nonbridgiDg external fixation technique usiDg multi-
2 mm and the DRUJ was stable in all ~ases. planar K-wires. J Hand Surg Am 2005;30A:960-968.
7. Graff S, Jupiter J. Fracture of the distal radius: classification of treat-
The plates were removed on average 112 days after
ment and indications for external fixation. Injury 1994;25(Suppl4):
pla~ent. 14-25.
Forty-one of the 62 patients have returned to their previ- 8. Handoll HH, Madhok R. Surgical interventions for treating distal
ous levels of employment. Of the remaining 21 patients, 8 radial fmctures in adults. Cochrane Database Syst Rev 2003(3):
were unemployed at the time of injury and remain so. CD003209.
Thirteen patients sustained multiple injuries requiring 9. Hanel DP, Lu TS, Weil WM. Bridge plating of distal radius frac-
~onsiderable manges in o~upation and lifestyle. Only 1 of
tures: the Harborvicw method. Clin Orthop Relat Res 2006;445:
these 13 patients ~onsiders the wrist fra~ture to be the lim- 10. Hastings H II, Lcibovic SJ. Indications and techniques of open reduc-
iting fa~tor in failing to return to work. tion: internal fixation of distal radius fractures. Orthop Clin North
Overall these results ~ompare favorably with the fmdings Am 1993;24:309-326.
of Burke and Singe2 and Rud et al. 17 11. Kamath AF, Zurakowski D, Day CS. Low-profile dorsal plating for
• Similarly, Rud et al 17 showed that 64% of patients ob- dorsally angulatcd distal radius fractures: an outcomes study. J Hand
tained ex~ellent radiographk and fun~tional results and an- Surg Am 2006;31:1061-1067.
12. Konrath GA, Bahler S. Open reduction and internal fixation of unsta-
other 27% of patients obtained good results in their prospe~­ ble distal radius fractures: results using the Trimcd fixation system.
tive ~ohort of patients with ~omparable pathology. J Orthop Trauma 2002;16:578-585.
• The authors of ead of these studies propose that distra~tion 13. Lafontaine M, Hardy D, Delincc P. Stability assessment of distal ra-
plating allows fra~ture redu~tion and fixation over a broad dius fractures. Injury 1989;20:208-210.
metadiaphyseal area while effectively diverting ~ompression 14. McQueen MM Non-spanning external fixation of the distal radius.
for~es away from the fra~ture site. Hand Clin 2005;21:375-380.
15. McQueen MM, Simpson D, Court-Brown CM. Usc of the Hoffman
• The use of bridge plating in the treatment of distal radius
2 compact external fixator in the treatment of redisplaccd unstable
fra~tures avoids the ~omplkations of external fixation. A
distal radial fractures. J Orthop Trauma 1999;13:501-505.
bridge plate ~an remain implanted for extended periods with- 16. Orbay JL, Touhami A. Current concepts in volar fixed-angle fixation
out deleterious effe~ts on fun~tional out~ome. All patients in of unstable distal radius fractures. Clin Orthop Relat Res 2006;445:
our series went on to heal with a~~eptable metadiaphyseal and 5s-67.
intra-arti~ular alignment. In patients with multiple traumati~ 17. Ruch DS, Ginn TA, Yang CC, et al. Use of a distraction plate for dis-
tal radial fractures with metaphyseal and diaphyseal comminution. J
injuries, bridge plating allowed earlier postoperative load
Bone Joint Surg Am 2005;87A:945-954.
bearing a~ross the affe~ted wrist. This enabled independent 18. Wolf JC, Weil WM, Hanel DP, et al. A bimncchanic comparison of
transfers and the use of ambulatory aids. Applkation of bridge an internal radiocarpal-spanning 2.4-= locking plate and external
plates is simple and surgi~al time is ~omparable with the appli- fixation in a model of distal radius fractures. J Hand Surg Am
~ation of an external fixator. 2006;31:1578-1586.
- Open Reduction and Internal
Fixation of Ulnar Styloid,
Chapter 14 Head, and Metadiaphyseal
f Tommy Lindau and Andrew J. Logan

• The distal ulna is the fixed poin~ around which the radius • Isolated ulnar fractures most commonly occur when the
and the hand function (FIG 1A). forearm is struck by an object, explaining the eponym "'night-
• Fractures of the distal ulna are often inadequately treated in stick fracture."
comparison to ita larger counterpart. the radius (FIG 1B,C). • Distal ulnar fractures are most often due to a fall on an out-
• The current literature gives little guidance as to the manage· stretched hand.
meat of these fractures and associated injuries. • It is a common understanding that ulnar-sided injuries are
more often caused by falls backward in which the forearm is
ANATOMY in supination, loading the ulnar side of the distal forearm and
• The ulnar head forms the fixed point on which the hand and wrist and causing distal ulnar fractures, triquettal chip frac-
radius rest'3 (FIG 2A). tures, 1FCC injuries, and so forth.
• The radius rotates around the ulnar head through the distal In contrast, radial-sided injuries are more often caused by
radioulnar joint (DRUJ) during forearm pronation and supina· falls forward, loading the radial side of the forearm and
tion.3 •4 wrist and causing scaphoid fractures, distal radius fractures,
• This joint is connected to the carpus by a complicated liga- and so forth.
ment apparatus, the triangular fibrocartilage complex (1FCC).
• The stability of the DRUJ is achieved through bony con· NATURAL IDSTORY
gruity betw«n the sigmoid notch of the radius and the ulnar • Many distal ulnar fractures leave only marginal long-term
head supported by the ulnoradialligaments1•4 (FIG 28). problems.
The spheres of the two articular surfaces differ (FIG 2C). • Some distal ulnar malunions cause DRUJ incongrueru:y with
Sixty percent of the joint surfaces are in contact in neutral subsequent instability or blocked forearm rotation (FIG 3 ). This
forearm position.1 is why management of these deceptive fractures is important.
In full pronation and supination there is only 10% bony
The ligamenta run from the fovea of the ulnar head and STUDIES
the base of the ulnar styloid to the dorsal and palmar edges • Posteroanterior, lateral. and oblique radiographs typically
of the sigmoid notch on the distal radius1•9 (Fig 2B). reveal the pathology.


FIG 1 • A. The distal ulna is the fixed point upon which performance of most daily hand activities depends.
B,C. Fractures of the distal ulna are often neglected in comparison to those of its larger counterpart,. the radius,
which always attracts attention and treatment efforts. The outcome after distal forearm fractures could be im-
proved if the fixed point-the distal ulna-is addressed surgically at the same time as the radius is operated on.


'\ I


A I c
FIG 2 • A. The distal ulna is the fixed point around which the radius rotates in pronation and supina-
tion. Through the ulnocarpal ligament the distal ulna relates to the hand, allowing daily hand activities.
B. The distal radioulnar joint is stable because of bony congruity between the ulnar head and the si~
moid notch on the radius. The ulnoradial ligament inserts in the fovea and the base of the ulnar styloid
and has a dorsal and palmar ligament attached to the dorsal and palmar part of the sigmoid notch re-
spectively. They act as reins in the pronation and supination motion. C. The spheres of the two articular
surfaces differ: the curvature of the ulnar head has a shorter radius, whereas the curvature of the sig-
moid notch has a greater radius.

A B c
FIG 3 • A,B. Radiographs showing a distal radius fracture together with an ulnar head and styloid
fracture. The complexity of the ulnar-sided injury was underappreciated. C. Intraoperative fluoro-
scopic image after fixation of the distal radius fracture, revealing displaced and unstable ulnar
fractures. (continued)


FIG :J • (continued) D.E. The distal radius fracture was stabilized using a volar locking plate. The ulnar head and sty-
loid fractures were partially reduced and fixed with two Kirschner wires. The surgeon adequately secured the ulnar
styloid fracture but not the ulnar head fracture and postoperatively did not restrict forearm rotation. F,G. These ra-
diographs reveal the eventual ulnar head malunion that resulted in distal radioulnar joint instability and diminished
forearm rotation. The situation was salvaged using an ulnar head replacement prosthesis.

• cr is useful in examining articular fractures of the ulnar head. ulnoradial ligament insertion site around the fovea of the ulnar
• MRI is sometimes needed to evaluate the integrity of the head at the base of the styloid (FIG 6A).
TFCC. Generally, ulnar styloid fractures should be operated on if
• Arthroscopy should be considered if a radiograph leads the the fracture is at the base of the ulnar styloid and is dis-
physician to suspect DRUJ dissociation without radiographic placed more than 2 mm11 (FIG 6B,C).
explanations, such as a displaced ulnar styloid base fracture. Radial translation of the fractured ulnar styloid is caused
by the detachment of the ulnoradial ligament. This increases
SURGICAL MANAGEMENT the indication (FIG 6D) more than axial, distal fracture dis-
Findings and Indications placement (detaching the ulnotriquettal collateral ligament).
Ulnar styloid fractures at the tip are likely to be stable
DRUJ Dissociation and do not require fixation, as the ulnoradial ligament re-
• Radiographs occasionally reveal DRUJ dissociation in the mains attached to the ulnar head at the base of the styloid
absence of an ulnar-sided fracture (FIG 4 ). This results from (FIG &E~F).
detachment of the ulnoradialligament8 (FIG SA). • Ulnar-sided injuries associated with distal radius fractures
Such ulnoradial ligament injuries have been found to cause should be carefully assessed radiographically and clinically
DRUJ laxity and a worse outcome after distal radius frac- after open reduction and intemal.6xation (ORIF) of the radius
tures in patients without osteoporosis7 (FIG 58). fracture.
Arthroscopically assisted repair or open repair and reat- Ulnar fracture reduction and DRUJ joint stability are
tachment of the ulnoradial ligament to the fovea of the ulnar often improved after treatment of the radius fracture.
head are required to restore stability in the DRUJ (FIG 5C) Stable DRUJ means that the ulnoradial ligament is not at-
(see Chap. HA-49). tached to the fractured ulnar styloid and therefore can be
treated nonoperatively.
Uhuw Styloid Pf'aaures
Unstable DRUJ indicates that the ulnoradial ligament is
• The importance of ulnar styloid fractures and the need detached with the styloid fracture. The styloid should be re-
for operative intervention depends on the involvement of the duced and stabilized or the ligament reattached.

FIG 4 • A. An undisplaced distal radius fracture

with no obvious distal ulna pathology. B. The same
fracture with a stress test to the distal radioulnar
joint (DRUJ}, and an obvious DRUJ dissociation is
seen as a sign of a complete ulnoradial ligament
detachment in the absence of an ulnar styloid
A B fracture.

A I c
FIG 5 • A. Arthroscopic view of an ulnoradial (peripheral triangular fibrocartilage complex,} detachment. The lunate
is seen at the top, the radius below, and the detached surface with bleeding at the right side. B. Distal radioulnar
joint dissociation after a distal radius fracture with a complete detachment of the ulnoradial ligament in the absence
of any ulnar-sided fracture. C. Arthroscopic view of an arthroscopically assisted repair and reattachment of an
avulsed ulnoradial ligament. The lunotriquetral interval is seen on top, the radius joint surface is seen in the lower
left corner, and the blue sutures are bringing down the ligament toward the fovea of the ulnar head, which is not
seen arthroscopically.

FIG 6 • A. The ulnoradial ligament has superficial and deeper components, which insert at the fovea of
the ulnar head and partly attach to the base of the ulnar styloid. Consequently, a fracture at the base of
the ulnar styloid may or may not detach the main distal radioulnar joint-stabilizing ligament. B,C. Ulnar
styloid fractures at the base may detach the ulnoradial ligament and should be operated on if they are
displaced more than 2 mm.11 D. Radial displacement (detaching the ulnoradial ligament) increases the
indication for surgical treatment. E,F. Ulnar styloid tip fractures represent avulsion fractures from the
ulnotriquetral collateral ligament. They demand no further treatment.

A B c D
FIG 7 • A,B. Abutment of the ulnar styloid into the triquetrum on the ulnar side of the carpus. C,D. An ulnar styloid nonunion
causing problems as a loose body.

Ulnar Styknd NOII#tdcm Ulna" Head FradUt'e$

• The main physical findings of ulnar styloid nonunion are • Ulnar head fractures are most often associated with distal
ulnar-sided wrist pain worse with loading in rotation and radius fractures, and the pattern of the distal radius fracture
tenderness over the ulnar styloid.5 Symptoms from an ulnar will have a strong influence on the overall .functional outcome.
styloid nonunion are related to the following: • Ulnar head fractures are seen either alone or with involve-
DRUJ instability from a malfunctioning ulnoradial liga- ment of extra-articular portions of the distal ulna. proximally
ment (peripheral TFCC detaclunent)5 (Fig SB) toward the diaphysis or distally including the styloid (Fig 3A,:B).
Impingement of the overlying extensor carpi ulnaris
(ECU) tendon Distal Ulna" Neck and Shaft Fmauru
Abutment on the carpus5 (FIG 7A,B) • A distal ulnar neck or distal shaft fracture .is a fracture that oc-
Soft tissue irritation from the loose body (FIG 7C,D) curs within 4 em of the distal dome of the ulnar head (RG IA-0).

A B c D

FIG 8 • A.B. This ulnar shaft fracture is by definition within 4 em of the distal dome of the ulnar head.
C.D. This ulnar shaft fracture is more proximal and should be considered an isolated ulnar fracture.
However, there may still be involvement in the distal radioulnar joint (DRUJ), which needs to be taken into
account. The DRUJ should be examined for stability after open reduction and internal fixauon. (continued)
137 -

FIG 8 • (continued) ~F. Unstable distal radius and ulnar

fractures are difficult to immobilize with casts alone. AP
and lateral views show comminution and dorsal displace-
ment in both fractures. This fracture cannot be treated
E F conservatively.

• Some distal ulnar fractures in association with distal radius • It is generally recommended that the initial approach be
fractures realign after manipulation and are considered to be geared toward restoring the anatomy and maintaining the
stable once the radius is reduced.10 overall alignment of the ulna and DRUJ.
• It is difficult to immobilize unstable fractures with a cast
alone. Three-point fixation, even in an above-elbow cast, is Approac:h
not effective (FIG 8E,F). • The described approach is used for all distal ulnar fractures,
including the ones extending into the neck of the ulna and into
Co~ ltlh'tl-.Aniadtw Distal f1ltuw Ff'adUres the distal shaft.
• Comminuted distal ulnar fractures that are irreducible and • This approach can, for instance, access an ulnar styloid frac-
cannot be reconstructed have been mentioned in the literature ture or nonunion and at the same time visualize, assess, and
in only one case report. 2 allow treatment of any associated TFCC pathology.


• Approach the distal ulna through a dorsal zigzag incision • Elevate the ulnar retinacular flap in the interval between
centered over the DRUJ (IEat RG 1AB) . the extensor retinaculum and the separate dorsal sheet
• This approach allows reattachment of all crucial stabi- for the ECU tendon.
lizing structures at the time of wound dosure. • Preserve the integrity of the separate ECU compart-
• carefully protect the dorsal sensory branches of the ment (IECH FIG 1E).
ulnar nerve (IECH FIG 1(). • Open the dorsal capsule of the DRUJ using an ulnarly
• Incise the retinaculum overlying the fifth extensor com- based flap raised from the 4-5 septum (IEat FIG 1F).
partment (IEat FIG 1D) . • Identify the 4-5 intercompartmental artery.

TEat FIG 1 • Surgical approach to all distal ulnar

fractures. A,B. A dorsal zigzag incision is made with
the center directed toward the distal radioulnar
A B joint. (continued)

TEat FIG 1 • (continued) C. Subcutaneous dissection should be performed so that the dorsal cutaneous branch from
the ulnar nerve is protected. D. The retinaculum is identified and an approach through the fifth extensor compartment
is done. E. The retinaculum is elevated as an ulnarly based flap between the true retinaculum and the separate dorsal
sheet for the extensor carpi ulnaris (ECU} tendon (which should be preserved}. The ECU is thereby kept in its tendon
sheath. F. An ulnarly based capsular flap is raised from the 4-5 septum to gain access to the distal ulna. G. As shown
in this dissected specimen, the ulnocarpal joint is often hidden behind the synovium over the meniscus homolog.
(C,D: Courtesy of M. Garcia-Elias, Spain.}

• Begin the capsular incision at the neck of the ulna and • The DRUJ and the spanning TFCC are then readily visual-
extend it to the 4-5 intercompartmental artery, which is ized. The ulnocarpal joint is often hidden behind the syn-
diathermied. ovium over the meniscus homolog (.1Eat FIG 1G).
• The incision continues along this line to the level of the • If required, remove the synovium dorsal to the uln~
radiocarpal joint, where it then extends distally and radial ligament to gain access to the ulnar styloid and
ulnarly along the dorsal radiotriquetral ligament to the the ulnocarpal joint.
triquetrum. • In cases of a distal neck fracture without any intra-
• By staying in a flat layer along the dorsal cortex of the articular involvement or soft tissue components, the
radius, the dorsal ulnoradial ligament attachment is approach stays proximal to the capsular flap. However,
not violated. the retinacular flap needs to be raised to address the
distal metaphyseal fractures.


• Options for fixation of ulnar styloid base fractures in- • Tension band wiring ClEat FIG ZC)
clude the following: • Wire loop or suture
• Single or double Kirschner wires (IECH FIG ZA,B) • Screw fixation ClEat FIG ZD)

A I c
TECH FIG 2 • The ulnar styloid can be fixed in various ways to secure reattachment of the ulnoradial! igament and thereby
stabilize the distal radioulnar joint. A,B. Single (not rotationally stable) or double Kirschner wires. C. Tension band wiring.
D. Screw fixation (not rotationally stable).


• Reattachment of the nonunited fragment to the ulnar • If the fragment is small and located distally and there is
head is indicated if the fragment is large.5 no DRUJ instability, the ulnar styloid can be excised wit~
• If the fragment is small, it should be excised and the ul- out any associated ligament procedure.5
noradial ligament reattached directly to the fovea of the
ulnar head.5


• Ulnar head fractures without a proximal extra-articular • The intra-articular component is reduced and stabi-
component lized.
• Fractures that are displaced (with an intra-articular • If the extra-articular component extends proximally
step off) or unstable are treated with ORIF using buried toward the neck of the distal ulna a condylar blade
headless compression screws' or Kirschner wires. plate is recommended ('IECH FIG 3), whereas tension
• Immobilization after fiXation depends on the stability band wiring is recommended if the extra-articular
of the fracture and its fiXation. component involves the ulnar styloid (rech Fig 20.
• Ulnar head fractures with a proximal extra-articular • Immobilization after fiXation depends on the stability
component of the fracture and its fiXation.

TECH FIG 3 • Irreducible or unstable distal fore-

arm fractures require open reduction and inter-
nal fixation.10 AP and lateral radiographs show
a dorsally displaced distal forearm fracture fixed
with a blade plate.


• Irreducible or unstable fractures require ORIF.10
• This can be achieved using either a condylar blade
plate10 (Tech Fig 3} or tension band wiring supplemented
by intrafragmentary saews (IEat RG 4}.

A I c
TEat FIG 4 • A.B. AP and lateral radiographs show a dorsally displaced distal forearm fracture. Open reduction
and internal fixation was performed using both a dorsoradial and a dorsoulnar approach to stabilize the frac-
tures. C. Because of the comminution around the ulnar styloid base, fixation was achieved with a suture loop.


• Three treatment options exist for comminuted intra- rotation that may not be corrected with a late sal-
articular distal ulnar fractures: vage procedure.
• Restoration of the anatomy and overall alignment of • Primary distal ulnar head replacement2
the ulna and DRUJ as mentioned above The theoretical advantage is reduced stiffness (from
This can be accomplished with manipulation and having early movement) and less DRUJ pain.
above-elbow cast immobilization alone or alterna- • Total or partial excision of the ulnar head as well as
tively by surgical means with temporary wiring or ex- DRUJ arthrodesis with distal ulnar neck resection
ternal fiXation. (Sauve-Kapandji procedure)
The potential problems with this management
technique are wrist stiffness and reduced forearm

POSTOPERATIVE CARE The outcome can surely be improved if distal ulnar frac-
tures are treated more directly and aggressively.
• Stable fixation of the distal ulnar complex still requires pro-
• The outcome will also improve if the relationship between
tection postoperatively with a below-elbow splint.
the ulnar styloid and the ulnoradial ligament is fully under-
• Intermediate stable .6xation requires 4 weeks of protection
stood and addressed.
using a sugartong-type splint to allow flexion and extension of
the elbow but protect against uncontrolled pronation and
• Unstable fixation after internal, external, or nonoperative • Stiffness of the DRUJ with limited pronation and supination
treatment requires above-elbow proted:ion in neutral fore ann ro- • Infection
tation to limit movement for the fust 6 wwks. There is otherwise • Nonunion
a risk that rotational forces will cause a nonunion or malunion. • Malunion

• Outcome is influenced by the fact that most distal ulnar 1. af E.bnswn F, Hagen CG. Anatomic:al studies on me geommy and
fractures are neglected in comparison to the more common stability of the disw radio ulnar joint. Scand J Plast Reconstt Surg
and more extensively treated distal radius fractures. 1985;19:17-25.

2. Grechenig W, Peicha G, Fellinger M. Primary ulnar head prosthesis 8. Lindau T, Arner M, Hagberg L. Intraarticular lesions in distal frac-
for the treatment of an irreparable ulnar head fracture dislocation. tures of the radius in young adults: a descriptive arthroscopic study
J Hand Surg Br 2001;26B:269-271. in 50 patients. J Hand Surg Br 1997;22B:638~43.
3. Hagert CG. The distal radioulnar joint in relation tu the whole fore- 9. Palmer AK, Werner FW. The triangular fibrocartilage complex
ann. Clin Orthop Relat Res 1992;275:56-64. of the wrist: anatomy and function. J Hand Surg Am 1981;6A:
4. Hagert CG. Current concepts of the functional anatumy of the distal 153-162.
radioulnar joint, including the ulnocarpal junction. Jn: Biichler U, ed. 10. Ring D, McCarty PL, Campbell D, et al. Condylar blade plate fixa-
Wrist Instability. Berlin: Martin Dunitt, 1996:15-21. tion of unstable fractures of the distal ulna associated with fractures
5. Hauck RM, Skahen niJ, Palmer AK. Classification and treatment of of the distal radius. J Hand Surg Am 2004;29A:103-109.
ulnar styloid nonunion. J Hand Surg Am 1996;21A:418-422. 11. May MM, Lawton JN, Blazar PE. illnar styloid fractures associ-
6. Jakab E, Ganos DL, Gagnon S. Isolated intra-articular fractures of ated with distal radius fractures: incidence and implications
the ulnar head. J Orthop Trauma 1993;7:290-292. for distal radioulnar joint instability. J Hand Surg Am 2002;
7. Lindau T, Adlercreutz C, Aspenberg P. Peripheral tears of the tri- 2 7A:965-971.
angular fibrocartilage complex cause distal radioulnar instability
after distal radius fractures. J Hand Surg Am 2000;25A:464-468.
- Corrective Osteotomy for
Chapter 15 Distal Radius Malunion
t David Ring, Diego Fernandez, and Jesse B. Jupiter

DEFINfTION • Risk factors for fracture instability include age, metaphyseal

comminution. dorsal tilt, ulnar variance, and lack of func-
• Distal radius malwlion is best defined as malalignment asso·
tional independence.
ciated with dysfunction.
• Manipulation of previously reduced fractures that redisplace
Malalignment does not always result in dysfunction. In
in a cast or splint signffies instability and is not worthwhile.
particular, the vast majority of older, low-demand patients
• Limitations of various treatment techniques may contribute
function very well with deformity.
to creation of a malunion.
• Dyafuncti.on can include loss of motion, loss of strength, or
pain.l,l,S Percutaneous pins alone may not be sufficient to maintain
aligrunent when there is substantial metaphyseal comminution.
• Pain can be the most difficult to associate with deformity.
External fixation alone without ancillary percutaneous
Osteotomy for pain-as with any surgery for pain-is rela·
pin fixation of the fracture
tively Wlpredictable and should be Wldertaken with caution.
Early removal of pins or an external .6xator. Settling of
Carpal malalignment, ulnocarpal impaction, and distal ra·
the fracture can also be observed after implant removal
dioulnar joint malalignment are all potentially painful and can
more than 6 weeks after injury, particularly when there is
be variably addressed.
substantial metaphyseal comminution.
• The relationship between distal radius malwlion and carpal
Nonlocked plates may loosen in the osteopenic metaphy-
tunnel syndrome is disputed. Some surgeons claim a direct
seal bone.
causal relationship as well as the ability to improve carpal tun·
• Complacence must be avoided. Many older patients desire
nelsyndrome with osteotomy alone.
optimal wrist alignment and function, and treatment decisions
ANATOMY should not be made on chronological age alone.
• Loss of alignment can be measured on radiographs.
• Angulation of the articular surface on the lateral view is
measured as the angle between a line connecting the dorsal • Ulnar-sided wrist pain can improve for a year or more after
and palmar lips of the distal radius articular surface on the lat· fracture of the distal radius, so patience is warranted.
eral view and a line perpendicular to the radius shaft. • Lack of forearm rotation may be related to capsular con-
• Ulnarward inclination (often called radial inclination, a mis· tracture or bony malalignment. For slight malunions, patience
nomer since the articular surface tilts toward the ulna) is mea· with exercises and rehabilitation is advisable.
sured as the angle between a line carwecting the ulnar limit and
the radial limit of the distal radius articular surface on the pos·
teroantftior (PA) view and a line perpendicular to the radial shaft.
• Ulnar variance is a better measure of shortening of the ra·
dius than radial length. It is measured as the distance between
two lines drawn perpendicular to the radial shaft on the PA
view, one at the level of the most ulnar corner of the lunate
facet and the other at the distal limit of the ulnar head.
Positive ulnar variance means that the ulna is longer than
the radius. Negative means the ulna is shorter.
• Loss of articular surface alignment can be measured on ra·
diographs as gap, step, or subluxation.
This is most accurately measured using Cf images (FIG 1 ).
• Sources of variability in radiographic measurements include
variation in the radiographs, imprecision in the measurement tech·
niques, and imprecision in the selection of the points of referen~
• Fractures of the distal radius heal rapidly. A malaligned Step= 8D
healing fracture can be considered a malunion within 4 to
FIG 1 • The arc method for measuring articular malalignment of
6 weeks of injury.
the distal radius. 'The distance between B and D is the articular
• Risk factors for fracture instability, loss of reduction, and step, and the distance between A and C is the maximum articular
malunion include age over 60 years, more than 20 degrees of gap. (After catalano LW Ill, Cole RJ, Gelberman RH, et al.
dorsal angulation, dorsal metaphyseal comminution, com· Displaced intriHirticular fractures of the distal aspect of the ra-
minution extending to the volar metaphyseal cortex, associ· dius: long-term results in young adults after open reduction and
ated fracture of the ulna, and displaced articular fracture. internal fiX.auon. J Bone Joint SUrg Am 1997;79A:12~1302.)

143 -

• While it is often stated that an extra-articular distal radius dissociative rather than the typical nondissociative carpal
malwlion leads to future arthrosis, there are no data to sup- malalignment usually associated with distal radius malwlion.
port this contention. • Grip strength is one measure of wrist dysfunction, but it is
After a recovery period of 1 to 2 years from fracture, the largely determined by pain and effort-both strongly influ-
functional deficits seem fairly stable. enced by psychosocial factors.
• Articular incongruity or subluxation in relatively nonarticular
areas can be reasonably well tolerated, but in most cases intra- IMAGING AND OTHER DIAGNOSTIC
articular incongruity will lead to arthrosis, pain, and dysfunc- STUDIES
tion. There is no clear time frame for these changes-indeed, • Posteroanterior and lateral radiographs of the wrist (FIG
symptoms do not cOlTelate well with radiographic anatomy and 2A-D) can be supplemented by specific radiographs for eval-
the predictors of arthrosis are not well established. uation of the joint surface, particularly for potential articular
FINDINGS Comparison with the opposite, uninjured wrist is useful
and serves as a template for surgical correction.
• Pain should be very discrete and specific. It is important that • cr, particularly three-dimensional cr, is useful to precisely
there be a direct correlation of the pain with a clear operative evaluate the joint surfaces (FIG 2E).
target. Vague, diffuse, or disproportionate pain should not be • Neurophysiologic tests (nerve conduction velocity and elec-
treated with osteotomy. Pain alone is not a good indication for tromyography) are ordered to evaluate any symptoms or signs
osteotomy, so the interview should elicit specific aspecta of the of carpal tunnel syndrome that may need to be addressed.
pain for which there is a good operative target and the risks of
surgery are justified. DIFFERENTIAL DIAGNOSIS
• Lack of motion should be clearly due to malalignment and
not due to pain or squeamishness-likewise for instability of • Stiffness: capsular stiffness and tendon adhesions
the distal radioulnar joint (DRUJ). • Numbness: idiopathic carpal tunnel syndrome
• Range of motion: A goniometer is used to measure wrist • Pain: another discrete source of pain or even idiopathic pain
flexion, extension, radial and ulnar deviation, supination, and
• Ulnocarpal compression: The carpus is forcefully ulnarly • Nonoperative management is appropriate for low-demand
deviated toward the ulna. and infirm individuals. Splints are weaned after 6 weeks of
Consistent reproduction of usual pain with ulnar devia- cast immobilization. Patients who struggle to regain motion
tion tasks is consistent with ulnocarpal impaction. may benefit from working with an occupational therapist or a
• The examiner can test for DRUJ instability by stabilizing the certified hand therapist. Normal activities are resumed in 3 or
radius and trying to subluxate the distal ulna dorsal and volar 4 months. The patient may return every 2 or 4 months or so
from the sigmoid notch of the radius. until satisfied with the result.
Substantially less stability than the opposite side may cor- • Patience is warranted in many situations, particularly for
relate with symptomatic DRUJ instability, but this is a very patients with ulnar-sided wrist pain thought due to an extra-
difficult and subjective test. articular malunion.
• Scaphoid shift test: Instability would indicate a possible This discomfort is the last pain to go away after a distal
scapholunate interosseous ligament tear, indicating a potential radius fracture and routinely lasts up to a year.

A c D

FIG 2 • A,B. AP and lateral radiographs of extra-articular dorsally

angulated malunion. C,D. PA and lateral radiographs of an extra-
articular dorsally displaced malunion. E. CT shows rotational defor-
mity associated with a volarly displaced extra...:srticular fracture.
E (Copyright Diego Fernandez, MD, PhD.}

SURGICAL MANAGEMENT • Distal radius osteotomy need not be performed urgently.

The patient should have demonstrated excellent exercise skills
• Surgery is appropriate when a radiographic deformity corre-
and full finger motion, and there should be no significant
lates with a specific anatomically correctable problem and the
nerve or tendon dysfunction or edema.
deformity is associated with a substantial risk of dyafuncti.on
In the case of an intra-articular malunion, intervening
and arthrosis.
early (optimally within 6 months, definitely within 1 year of
The patient must Wlderstand the risks and benefits of in-
the fracture) when the fracture is not completely healed may
take precedence over these concerns.
The surgeon should be wary of pain as the primary com-
plaint, because pain is strongly influenced by psychosocial Preoperative Planning
factors, and pain relief is an achievable goal only when con- • The desired angular, rotational, and length e<>.rm:tions are
sistent with an objective, e<>.rm:table anatomic deformity planned based on preoperative radiologic studies, including a
such as discomfort dearly associated with a substantial ul- radiograph of the opposite wrist if uninjured (FIG 3A,B).
nocarpal impingement. • It can be useful to draw and write out a reconstruction plan,
When the issue is restriction of motion and there is less particularly for complex malunions (FIG 3~). In that way
than 20 degre<:s of dorsal tilt or less than 5 mm of ulnar pos- every contingency is anticipated and the surgery is likely to go
itive variance, a nonoperative approach may be warranted. more smoothly.
• There are no fixed rules or thresholds for acceptable align-
ment. The correlation with symptoms and dysfunction is more Positioning
important. • The patient is positioned supine with the ann supported on
• Intra-articular osteotomies should be considered only when a hand table.
the malalignment is simple and the planned correction is • A nonsterile pneumatic tourniquet is used and inflated after
straightforward. exsanguination and before the skin incision.
For instance, malalignment of volar shearing fracture
would be considered when the fragment is large, there is Approach
little or no articular comminution or impaction, and the • The operative approach is either dorsal or volar, depending
dorsal fragments are not healed in a malaligned position. on the deformity and the chosen surgical technique.

--._!0 • 10° . ~..

AG J • A.B. Preoperative plans for dorsal osteotomy in
the patient in Techniques Figures 1 to 3: preosteotomy
plan (A,} and postosteotomy and corticocancellous bone
grafting plan (B}. C. Preoperative plan for an extra-
articular osteotomy through a volar approach in the
B patient in Techniques Figures 4 and 5. (continued)

FIG 3 • (continued) D.E. Preoperative plans for an inu-a-anic-

ular dorsally angulated malunion in the patient in
D E Techniques Figure 6. (Copyright Diego Fernandez. MD, PhD.)


Exposure • Elevate the fourth dorsal compartment and its tendons
• Make a longitudinal incision centered over the tuber-
• Preserve the integrity of this compartment.
cle of Lister, in line with the third metacarpal ('IEat
• It is usually not possible to elevate the second dorsal
FIG 1A).
compartment subperiosteally, so simply retract the ex-
• Elevate skin flaps, taking care to protect the branches of
tensor carpi radialis brevis and longus tendons radial-
the superficial radial nerve in the radial skin flap.
ward after opening the compartment.
• Incise the retinaculum over the third extensor com-
partment. Remove the tendon of the extensor
pollicis longus (EPL) and transpose it radialward Osteotomy and Realignment
('IEat FIG 1B). • Kirschner wires drilled parallel to the articular
• The EPL tendon will be left in the subcutaneous tis- surface can facilitate monitoring of realignment
sues at the completion of the procedure. ('IEat FIG 2A).
• A distractor or small external fixator may facilitate re-
alignment and provisionally stabilize the fracture.
• The proximal threaded pin is drilled into the radial
diaphysis perpendicularly in a position that will not
interfere with implant application.
• The distal threaded pin is drilled at an angle equal to
the desired correction of the lateral tilt of the distal
radius articular surface so that distraction of the two
pins will bring this pin parallel to the proximal pin
(perpendicular to the radius), thereby restoring
• The pins should be drilled so that they also help re-
store the appropriate ulnarward inclination of the
distal radius articular surface when distracted.
• Planned angular corrections can be monitored with
sterile geometric templates.
• The osteotomy is made parallel with the distal Kirschner
wire and as close to the original fracture site as possible
using an oscillating saw (IEat RG 2B).
• If the fracture is not yet completely healed (nascent
malunion-usually within 4 months of injury), recreate
the original fracture line by carefully removing fracture
callus at the fracture site.
• This callus can be saved and used as bone graft.
If the fracture is solidly healed, attempt to identify the
'IEat FIG 1 • Correction of extra-articular dorsally angulated prior fracture site. If this is uncertain, choose a site that
malunion in the patient in Figure 2A,B. A. Straight longitudi- creates a distal fragment large enough to facilitate ma-
nal skin incision. B. The extensor pollias longus is mobilized nipulation and internal fixation while trying to stay dis-
and transposed dorsoradially into the subcutaneous tissues. tal enough to take advantage of the healing capacity of
(Copyright Diego Fernandez. MD, PhD.) metaphyseal bone.

TEat FIG 2 • A. Kirschner wires are placed parallel to the articular surface. Fluoroscopic image
showing pin placement. B. The osteotomy is made with a saw as dose as possible to the original
fracture site. C. Lateral fluoroscopic image showing use of a lamina spreader to realign the distal
fragment. D. The osteotomy has been opened and is ready for graft placement. (Copyright Diego
Fernandez, MD, PhD.}

• A lamina spreader can be used to help realign the distal morbidity associated with harvest of a standard iliac
fragment as well (IEat FIG 2C.D}. crest bone graft.
• care must be taken when operating on osteoporotic • Apply a singleT- or Pi-shaped plate or two 2.~ or 2.4-mm
plates (one applied dorsally, ulnar to the tubercle of
• Additional provisional stability can be provided by plac- Lister, and the other applied radially between the first
ing 1.6-mm smooth Kirschner wires. and second dorsal compartments}.
• If the ulnar variance can be restored with angular re- • When a structural, corticocancellous bone graft is
alignment alone, the volar cortex can be cracked and used, a single plate or a plate and separate screw may
hinged open in an attempt to maintain some stability of be adequate (IECH FIG 3D-H).
the osteotomy. If lengthening of the volar cortex is re- • Plates with angular stable screws or blades in the dis-
quired to restore ulnar variance, a second distractor in tal fragment may be more reliable than standard
another plane (eg, direct radial) may prove useful for ob- screws, particularly if the bone is of poor quality and
taining and maintaining alignment. if nonstructural graft is chosen.

Graft Insertion and Fixation

• Once implants are placed and stability is ensured, re-
move all provisional fiXation devices.
• Once the osteotomy is created and the radius realigned, • This entire process is monitored using image intensifica-
tion to confirm appropriate osteotomy site, correction of
bone graft is inserted.
• Harvest bone graft ClEat FIG 3A). Either a corticocancel- alignment, and implant placement.
lous (structural) bone graft or cancellous bone graft can • Repair the extensor retinaculum with absorbable suture•
• In some cases, a flap of retinaculum is brought deep
be used.
• Potential advantages of a structural graft include i~ to the tendons to add a layer of protection between
mediate structural support (1Eat FIG 31) and the the implants and extensor tendons.
possibility of using a smaller implant and thereby • We usually do not close the retinaculum, and we no
avoiding tendon irritation. longer make retinacular flaps.
• A cancellous (nonstructural) bone graft can be har- • The tourniquet is deflated and hemostasis ensured•
vested using trephines (IEat RG 3C}. This avoids te- • The skin is closed •
dious, difficult, and unpredictable harvest and con- • A bulky dressing incorporating a volar plaster wrist splint
touring of corticocancellous grafts, as well as the is applied.
147 -

1ECH RG 3 • A. Corticocancellous bone graft is harvested from the iliac crest. B. After final 5eulpting it is applied
to the osteotomy site. C. Autogenous cancellous bone graft is harvested from the iliac crest using a trephine. D. A
2.0-mm condylar blade plate can provide fiXed-angle internal fixation. f,F.Intraoperative photographs ofthe fiX-
ation. G,H. Final AP and lateral radiographs. (Copyright Diego Fernandez. MD, PhD.)


Exposure • If more exposure is required, the incision is angled or
zigzagged at least 45 degrees toward the 5eaphoid
• Use a volar-radial Henry (flexor carpi radialis [FCR]) ap-
distal pole.
proach for both dorsally and volarly angulated malu-
nions (see Fig 2C.D). • Incise the FCR sheath, retract the tendon ulnarly, and i~
cise the floor.
• Make a 5- to 7-cm longitudinal incision over the FCR te~
• Leave the radial artery undissected and protected in
don ending at the wrist flexion crease. the radial soft tissues.


TECH FIG 4 • Realignment and provisional foortion of an extra-articular dorsally displaced

D malunion in the patient in Figure 2C,D.

• Sweep the fat overlying the pronator quadratus to- realignment by pushing the distal fragments into posi-
gether with the digital flexors and median nerve ulnar- tion as the proximal screws are tightened.
ward with a sponge or blunt elevator.
• Proximally in the incision, elevate the most distal aspect
of the origin of the flexor pollicis longus from the volar
Realignment and Provisional
distal radius (taking care to cauterize a consistent artery
• The fragments are realigned using the techniques
in this region) and retract it ulnarly with a small
described above (IEat RG 4).
Hohmann retractor placed around the ulnar border of
• The techniques are similar to those for acute fractures
the radius.
once an adequate soft tissue release has been
• Expose the radial border of the radius using a blunt el~
vator and Hohmann retractors.
• Apply a fixed-angle volar implant.
• Incise the pronator quadratus over its most radial and
• Insert provisional Kirschner wires either through or adja-
distal limits (l-shaped incision) and elevate it sub~
cent to the plate (see Tech Fig 4).
• Leaving the periosteum with the muscle can facilitate
later repair. Plate Fixation
• For dorsally angulated malunions, release of the radial • Placement of the plate will frequently help reduce the
and dorsal soft tissues facilitates realignment. proximal and distal fragments (IEat FIG 5A,B).
• The brachioradialis is Z-lengthened and the perios- • After final plate fixation and removal of provisional
teum is elevated from the radius shaft proximally. fixation, apply cancellous graft to the osteotomy site
• After osteotomy in the manner detailed above (for the
dorsal approach to malunions), pronate the proximal ra-
(IEat RG SC~.
• Excellent access is available radially for placement of
dius shaft out of the wound, providing access to the dor- the bone graft.
sal periosteum, which can be isolated and divided. • The tourniquet is deflated and hemostasis ensured.
• With the release of the brachioradialis and the dorsal • Repair the pronator quadratus if possible.
periosteum, realignment of the radius is usually com- • It can be sutured to the brachioradialis tendon.
parable to an acute fracture. • The skin is closed.
• Volarly angulated malunions do not need an extensive • A bulky dressing incorporating a volar plaster wrist splint
soft tissue release in most cases. The plate can facilitate is applied.

1Eat RG 5 • A. Fluoroscopic image of plate fixation and realignment. B. Defect after correction. Autogenous
cancellous graft. (C) and graft placement (D), showing final clinical appearance. f,F. Final PA and lateral radi-
ographs. (Copyright Diego Fernandez, MD, PhD.)


• Intra-articular osteotomy should be attempted only necessary to remove bone or callus from the fracture site
when there is a simple fracture line that can be clearly to realign the fracture fragment. Callus or bone is re-
identified by direct visualization as well as under image moved until the fracture fragment fits properly (IEat
intensification (1Eat FIG 6A-C). FIG 6D).
• Incompletely healed fractures (fewer than 3 to 4 • Provisional Kirschner wires are used to hold the reduc-
months since injury) are ideal. tion (IEat FIG 6f,F).
• Depending on the locations of the malunited articular • The implants are then applied.
fragments, perform either a dorsal or a volar exposure in • Dorsally a single T- or Pi-$haped plate or two 2.~ or
the manner detailed above. 2.4-mm plates (one applied dorsally, ulnar to the tu-
• When a dorsal exposure is used, a transverse capsulo- bercle of Uster, and the other applied radially between
tomy allows access to the joint and monitoring of the the first and second dorsal compartments) can be used
articular osteotomy and realignment. (IEat RG 6G,H).
• In the case of a volar exposure, the capsule is not in- • Volarly, aT-shaped plate is usually used.
cised, but articular exposure may be possible through • After final plate fixation, provisional fixation is re-
the osteotomy site. moved.
• The osteotomy should recreate the original fracture • This entire process is monitored using image intensifica-
line. This is monitored directly and under image inten- tion to confirm appropriate osteotomy site, correction of
sification. alignment, and implant placement.
• Reduction is accomplished by soft tissue release and di- • Deflate the tourniquet, close the wound, and apply the
rect fragment manipulation. For many malunions it is splint in the manner detailed above.

A B c


'IECH FIG 6 • A-C. PA and lateral radiographs and CT of an intra-articular dorsally angulated malunion. D. A Freer elevator is
used under fluoroscopy to reposition the articular fragment. E,F.Intraoperative fluoroscopic views showing provisional correc-
tion and fixation. G,H. Final plate and screw fixation. (Copyright Diego Fernandez, MD, PhD.)


Preoperative plan • A poor or incomplete preoperative plan will increase the amount of uncertainty and hesitation
during surgery. This will increase the operative time and the frustration level and will decrease
the satisfaction with the surgery.
• Making a detailed preoperative plan will improve the efficiency and efficacy of the procedure.
Extra-articular mal unions • Manipulating the distal fragment can be much more difficult with poor-quality bone.
• The use of a distractor or small external foortor greatly facilitates realignment and provisional
stabilization of the fragments.
• Consider using two distractors in perpendicular planes (eg, one dorsal and one direct radial) to
help obtain and maintain alignment.
• Restoration of length in addition to that gained with angular realignment (ie, lengthening of
both the dorsal and volar cortices) is much more difficult.
• The most difficult part of performing an osteotomy for a dorsal angulated malunion from a volar
approach is realignment of the bone.
• An extended FCR exposure allows release of the dorsal periosteum and Z-lengthening of the
brachioradialis, both of which facilitate realignment