1 Preliminary remarks topenlarge
Fracture assessment and decision making
In A2.3 type fractures, the distal fragment is displaced in a palmar direction. These are often referred to as Goyrand or Smith fractures. Due to the pull of the flexor tendons, the fragment tends to redisplace after closed reduction.
The treatment of choice, therefore, is palmar buttress plating.
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 Reduction topenlarge
Reduce the fracture using the following steps:
- Increase palmar angulation to disimpact
- With traction applied, in association with distal pressure on the metaphyseal fragment, extend the hand and wrist
Final anatomical reduction can be achieved by direct manipulation, using a dental pick or similar hook.
A smooth K-wire is placed through the radial styloid across the fracture site into the opposite radial cortex to secure the reduction.
Pitfall: Over reduction
Care must be taken not to over reduce the distal fragment and create a dorsal displacement of the distal fragment. After confirmation of reduction under image intensification, the distal fragment should always be secured with plate and screws.
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 into the oblong plate hole in the proximal radial fragment. Select a screw which is long enough to engage both cortices.
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 with the angle of the X-ray beam directed 20° obliquely to the radius in order to control that the screw is not penetrating the radial carpal joint.
Insert remaining screws
Insert at least 3 distal locking head screws.
Then insert at least two more proximal screws.
Remove the K-wire.