Executive Editor: Steve Krikler

Authors: Renato Fricker, Jesse Jupiter, Matej Kastelec

Distal forearm 23-C3 ORIF

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Glossary

1 Preliminary remarks top

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Type C fractures are complete articular fractures of the distal radius.
 
C3 type fractures involve a multifragmentary fracture of the articular surface. They are subdivided according to the extent of the metaphyseal fragmentation, varying from those involving only comminution of the articular surface with a simple metaphyseal fracture (C3.1), to those involving a multifragmentary metaphyseal fracture as well (C3.2), and the most complex, with multifragmentary fracture lines extending into the diaphysis (C3.3).
 
As these are intraarticular fractures, where possible, they should be treated with anatomic reduction and absolute stability in order to minimize the risk of subsequent degenerative changes in the joint.
 
Anatomical reduction and stabilization of these articular fractures is also essential because of the functional implications of the involvement of the distal radioulnar joint.
 
C3 fractures are among the most common fractures seen and treated in the older population, with underlying osteoporosis. When these fractures occur in younger individuals, they are more likely to be the result of high energy trauma, with associated soft-tissue, or skeletal injuries.

It is not possible to make an accurate assessment of the details of these injuries without a CT scan.


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Provisional reduction in displaced fractures

Reduction is achieved by applying longitudinal traction either manually or using Chinese finger traps.

The reduction is maintained by a temporary splint.

If definitive surgery is planned, but cannot be performed within a reasonable time scale, a temporary external fixator may be helpful.

2 Associated injuries top

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Median nerve decompression

If there is dense sensory loss, or other signs of median nerve compression, the median nerve should be decompressed.


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Associated carpal injuries

These injuries may be associated with shearing injuries of the articular cartilage, scaphoid fracture and rupture of the scapholunate ligament (SL). Every patient should be assessed for this injury. If present, see carpal bones of the Hand module.


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DRUJ/ulnar injuries

These injuries may be accompanied by avulsion of the ulnar styloid and/or disruption of the DRUJ. If there is gross instability after the fixation of the radial fracture, it is recommended that the styloid and/or the triangular fibrocartilaginous disc (TFC) is reattached (see A1.1). This is not common in simple fractures, but may occur with some high energy injuries.

The uninjured side should be tested as a reference for the injured side.
It may not be possible to assess DRUJ stability until the fracture has been stabilized (as described below).

3 Operative rationale top

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The rationale for using both palmar and dorsal approaches includes: the hyperextended palmoulnar fragment (intermediate column) and the rotated radial styloid (radial column) requiring a palmar approach; and the displaced dorsoulnar fragment and the impacted central articular fragment (intermediate column) that require a dorsal approach and arthrotomy.

4 Reduction and fixation of the palmoulnar and radial styloid fragments top

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Reduction of the palmoulnar fragment

If only the palmar lunate facet fragment needs to be stabilized, an ulnopalmar plate can be used. This is applied via an ulnar palmar approach.

After direct reduction of the palmoulnar fragment, an appropriate plate is inserted.

A screw is inserted through the oblong hole to allow longitudinal adjustment of plate position.


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As an alternative, a palmar plate may be applied through a modified Henry approach.


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Preliminary fixation of the palmoulnar fragment

The palmoulnar fragment itself is now secured to the distal transverse limb of the plate with a short locking head screw.


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Buttressing of the radial column

A radial S-shaped plate of appropriate length is chosen to buttress the radial column, and is contoured further as necessary. This is applied through a dorsal approach.

The plate is positioned and fixed to the diaphysis using a standard cortical screw through the oblong hole. A pointed reduction forceps is then used to reduce the radial styloid fragment and to hold the plate in place.

At this stage, reduction and plate position are checked by image intensification.


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Definitive fixation

After confirming the correct position of the palmar plate, it is secured definitively with a second standard cortical screw through its most proximal hole.

After confirming the correct position of the radial plate, it is fixed definitively with a second screw through its most proximal hole. The radial styloid fragment is secured with a short locking head screw.

5 Reduction and fixation of the intermediate column top

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Reduction of the central articular fragment

After gentle retraction of the dorsoulnar fragment, the large articular fragment that is impacted into the metaphysis is identified.

The fragment is levered up and reduced onto the proximal carpal row.
In this illustration, the overlying ulna and the radial plate have been omitted in the interest of clarity.


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Reduction of the dorsoulnar fragment

The retracted dorsoulnar fragment is then replaced and preliminarily secured with a K-wire that additionally holds in place the reduced central articular fragment.
The radiocarpal joint surface is checked for residual gap, or step off.

Note

If a large metaphyseal defect is created by elevation of the central impacted fragment, and especially if a nonlocking plate is used, autogenous cancellous bone should be packed into the gap, prior to reduction of the dorsoulnar fragment.


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Plate selection and preparation

An appropriate plate is selected according to the fracture configuration. The choice of the plate (T-, or L-shaped) is determined by the fracture pattern. If necessary the plate can be contoured.

A plate which allows variable angle locking screws may be very useful in this situation.


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Plate application

Fix the plate provisionally with a standard cortical screw through the oblong hole.

Check the reduction and position of the implants using image intensification.

If necessary, adjust the reduction and plate position, then tighten the screw.


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Image intensifier control

Reduction and plate position are checked at this stage using image intensification.

Provided the radiocarpal joint has been reconstructed and there is no major step off, a slight residual dorsal tilt of the radiocarpal joint line, in the lateral view, can be accepted.


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Definitive fixation of plate

After confirming the correct position of the plate using image intensification, it is fixed to the bone with a second standard cortical screw through its most proximal hole, and the screw through the oblong hole is then tightened fully.


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Locking head screws are then inserted distally to secure the dorsal fragments of the radiocarpal joint.

6 Assessment of Distal Radioulnar Joint (DRUJ) top

Before starting the operation the uninjured side should be tested as a reference for the injured side.

After fixation, the distal radioulnar joint should be assessed for forearm rotation, as well as for stability. The forearm should be rotated completely to make certain there is no anatomical block.


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Method 1

The elbow is flexed 90° on the arm table and displacement in dorsal palmar direction is tested in a neutral rotation of the forearm with the wrist in neutral position.

This is repeated with the wrist in radial deviation, which stabilizes the DRUJ, if the ulnar collateral complex (TFCC) is not disrupted.


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This is repeated with the wrist in full supination and full pronation.


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Method 2

In order to test the stability of the distal radioulnar joint, the ulna is compressed against the radius...


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...while the forearm is passively put through full supination...


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...and pronation.

If there is a palpable “clunk”, then instability of the distal radioulnar joint should be considered. This would be an indication for internal fixation of an ulnar styloid fracture at its base. If the fracture is at the tip of the ulnar styloid consider TFCC stabilization.

2016-10-17