1 Preliminary remarks topenlarge
Fracture assessment and decision making
In A2.1 type fractures, a metaphyseal fracture is present with no dorsal tilt.
In weak bone (osteoporosis), these fractures may be unstable in a cast and may shorten. If shortening of the radial metaphysis results in relative ulnar overlength, painful ulnar impaction may occur.
When the distal fragment is disimpacted, if there is a significant void created, a palmar locking plate is an effective means of stabilizing the fracture.
Advances in plate design have provided angular stable fixation. This allows enhanced stability and ease of application, even in the presence of osteoporotic bone. Plates with variable angle locking screw options may be useful.
2 Open Reduction topenlarge
Once the fracture is exposed, longitudinal traction is applied to try to disimpact the distal fragment.
If the distal fragment is not easily disimpacted with traction alone, a periosteal elevator may be inserted into the fracture to help lever the distal fragment into position.
Release the insertion of brachioradialis to make disimpaction easier.
Provisional K-wire fixation
Insert a K-wire across the fracture, through the radial styloid, to provide provisional stabilization.
Confirm the reduction under image intensification.
3 Plate fixation topenlarge
Apply the plate to the bone. The distal end of the plate should end at the anatomic watershed zone of the distal radius.
Insert a screw through an oblong hole in the proximal radial fragment. Before fully tightening it, check the plate position using intraoperative imaging, adjusting the position of the plate as necessary.
The initial distal screw should be placed through the ulnar sided screw holes.
The reason for this is that if the initial screw is placed on the radial side it will block accurate imaging of the ulnar screw placement.
A sagittal image is obtained with the angle of the X-ray beam directed 20° obliquely to the radius in order to confirm that the screw is not penetrating the radial carpal joint.
Insert remaining screws
Insert at least 3 distal locking head screws.
Insert at least two more proximal screws.
Remove the K-wire.