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• Screws without threaded heads can be used to secure
fragments that require drilling at an angle other than
possible with the fixed-angle holes in the T portion of
the plate.
• Recheck plate and screw position with intraoperative
radiographs.
• Place pronator quadratus over plate. Close skin.
Suggested Readings
Postoperative Care
• Immediate finger motion and forearm rotation
• Short arm plaster splint and bulky bandage for 2 weeks
• Short arm molded plastic for 2 weeks. If the fixation
is stable, the splint can be removed for gentle wrist
motion.
Orbay JL, Fernandez DL. Volar fixation for dorsally dis-
placed fractures of the distal radius: a preliminary
report. J Hand Surg 2002;27A:205–215
Orbay JL, Fernandez DL. Volar fixed angle plate fixation
for unstable distal radius fractures in the elderly
patient. J Hand Surg 2004;29A:96–102
■ 14 SECTION I OVERVIEW OF DISTAL RADIUS FRATURES
Open Treatment of Galeazzi Fractures6
Indications
Any displaced fracture of the distal radius with an
associated dislocation of the distal radioulnar joint
(DRUJ) (Fig. 6–1)
Technique
• Palmar approach via zigzag incision over flexor carpi
radialis (FCR) sheath (Fig. 6–2)
• Retract FCR radially.
• Incise floor of FCR sheath.
• Elevate pronator quadratus off of radius by subperiosteal dissection working from radial to ulnar.
• Extend the dissection proximally, elevating and
retracting the fibers of the flexor pollicis longus in a
radial direction.
Figure 6–1
Figure 6–2
CHAPTER 6 OPEN TREATMENT OF GALEAZZI FRACTURES 15 ■
Figure 6–3
• Debride fracture site and attempt provisional reduction.
• Apply palmar plate with provisional fixation: 2
screws distally and 2 screws proximally (Fig. 6–3).
• Check plate and fracture position with intraoperative
radiographs.
■ Pitfall
Check the position of the distal ulna on the lateral
radiographs. Check the forearm rotation. If the ulna is not
colinear with the radius on a lateral projection, or if there
is a block to forearm rotation, carefully check the alignment of the radius. The most common reason for lack of
forearm rotation is malalignment of the radius.
Figure 6–4
• Fill remaining holes in the plate. Recheck alignment of the radius and hardware placement (
6–4).
• Check the stability of the distal radioulnar joint with
the forearm supinated, pronated, and in a neutral
position (Fig. 6–5).
• If the ulna is stable in supination, consider immobilizing the forearm in supination.
Fig.
■ 16 SECTION I OVERVIEW OF DISTAL RADIUS FRACTURES
Figure 6–5
CHAPTER 6 OPEN TREATMENT OF GALEAZZI FRACTURES 17 ■
• If the ulna is unstable in all positions, consider pinning the distal radioulnar joint with the forearm in
neutral.
■ Pearl
Use two 0.62 in. pins to stabilize the distal radial ulnar
joint. Insert the pins through the metaphysis of the radius
exiting the radial cortex. If the pins break, they can be
retrieved through either cortex.
Suggested Readings
Postoperative Care
• Immediate finger motion and forearm rotation
• Long arm splint in supination if pins are not used
and in neutral if pins are placed
• Begin forearm rotation at 4 weeks.
• Use static progressive splinting for limited forearm
rotation once there is radiographic evidence that the
radius has healed.
Faierman E, Jupiter JB. The management of acute frac-
tures involving the distal radioulnar joint and distal
ulna. Hand Clin 1998;14:213–229
Kraus B, Horne G. Galleazzi fractures. J Trauma 1985;24:
1093–1095
Strehle J, Gerber C. Distal radioulnar joint function after
Galleazzi fracture-dislocation treated by open reduction
and internal plate fixation. Clin Orthop 1993;293:
240–245
■ 18 SECTION I OVERVIEW OF DISTAL RADIUS FRACTURES
Section II
Distal Radius
Malunions and
Nonunions
7
Extension Osteotomy for the Malunited Distal Radius
Indications
• Wrist pain, limited wrist motion (especially flexion),
and limited forearm rotation
• Deformity of the radius (Fig. 7–1)
• Loss of radial length due to dorsal tilt of articular surface
Preoperative Evaluation
• Template: must decide whether to correct dorsal tilt
alone or correct dorsal tilt and lengthen dorsal and
palmar cortex
• Prepare the patient for the possibility of a resection of
the distal ulna if a block to forearm rotation persists
after restoring the shape of the radius, or if there is
arthritis of distal radioulnar joint (DRUJ).
Technique
• Use dorsal approach to the radius.
• Remove the extensor pollicis longus (EPL) from the
third compartment and retract radially.
• Z-lengthen the retinaculum of the fourth compartment and retract the extensor digitorum communis
(EDC) tendons ulnarly (Fig. 7–2).
Figure 7–1
Figure 7–2
■ 20 SECTION II DISTAL RADIUS MALUNIONS AND NONUNIONS
■ Pearl
Do not violate the palmar cortex if length can be restored
by osteotomy of the dorsal cortex alone. An intact palmar
cortex adds to the stability of the osteotomized bone. This
allows the use of narrow, low-profile plates to stabilize
the dorsal cortex.
• Correct malposition. Maintain corrected position
with Gelpy retractors K-wires (Fig. 7–2). Check
position with intraoperative imaging.
• Harvest iliac crest bone graft (ICBG) tricortical graft to
match size of defect and additional cancellous bone.
• Press fit ICBG to defect.
• Check position with intraoperative image.
• Stabilize with dorsal plate: place distal and proximal
screw. Check position with intraoperative imaging
(Fig. 7–4).
Figure 7–3
• Place spinal needle into radiocarpal joint to show
plane of the articular surface.
• Drill K-wire into dorsal aspect of radius at expected
level of osteotomy parallel to spinal needle. Check
position with fluoroscopy (Fig. 7–3).
■ Pearl
The osteotomy should be
• Parallel to the joint
• In the metaphysis; preferably through the original
fracture line of the distal fragment
• Proximal enough to allow adequate fixation
• Complete the osteotomy in line with K-wire using
osteotome or oscillating saw with generous irrigation.
Figure 7–4
CHAPTER 7 EXTENSION OSTEOTOMY FOR THE MALUNITED DISTAL RADIUS 21 ■
■ Pearl
When the EPL tendon is transposed there is an 1 cm
space between the extensor carpi radialis tendon and
the EDC tendons. If the palmar cortex is intact and the
press fit ICBG creates a stable radius, a 2.0 or 2.4 mini
fragment plate can be used to stabilize the radius and
secure the graft. If, following plating, the construct does
not appear secure use a larger plate or supplement the
fixation with two 0.062 in. pins inserted from the radial
styloid.
• Fill remaining screws. Check appearance of DRUJ
and quality of rotation. If radius is reduced and
there is a block to rotation or coexisting arthritis
of the DRUJ, consider Darrach resection in older,
low-demand patient; hemiresection of the distal
ulna in a younger, high-demand patient. (Fig. 7–5)
• Close, laying one flap of retinaculum over plate and
one over tendons.
Postoperative Care
• Short arm splint for 2 weeks
• Short arm cast until the osteotomy has healed
Figure 7–5
Suggested Readings
Fernandez DL. Reconstructive procedures for malunion
and traumatic arthritis. Orthop Clin North Am 1993;24:
341–363
Alternative Techniques
• Corrective, extension osteotomy of the distal radius
can be performed through a palmar approach using
palmar plate with locking screws.
• In malunions treated within the first few months it
is often possible to use banked bone instead of iliac
crest bone graft.
Ladd AL, Huene DS. Reconstructive osteotomy for malu-
nion of the distal radius. Clin Orthop 1996;327:
158–171
■ 22 SECTION II DISTAL RADIUS MALUNIONS AND NONUNIONS
8
Dorsal and Palmar Osteotomy for Malunion of Distal Radius with Iliac Crest Bone Graft
Indications
• Wrist pain, limited wrist motion (especially flexion),
and limited forearm rotation
• Deformity of radius
• Dorsal tilt of articular surface
• Loss of radial length due to shortening from both dorsal
tilt of the radius and shortening of the palmar cortex
Preoperative Evaluation
Template: must decide whether to correct dorsal tilt alone
or correct dorsal tilt and lengthen dorsal and palmar cortex
Discuss the possibility that the radius cannot be restored
to its anatomical length. This may create the need to perform
a resection of the distal ulna to restore forearm rotation.
Technique
• Dorsal approach between third and fourth extensor
compartment internal via Z-lplasty of retinaculum
(Fig. 8–1)
• Place spinal needle into radiocarpal joint to show
plane of the articular surface.
• Drill K-wire into dorsal aspect of radius at expected
level of osteotomy parallel to spinal needle. Check
position with fluoroscopy.
■ Pearl
The osteotomy should be
• Parallel to the joint
• In the metaphysis; preferably through the original
fracture line of the distal fragment
• Proximal enough to allow adequate fixation
• Complete the osteotomy in line with the K-wire using
an osteotome or an oscillating saw with generous irrigation.
• Correct malposition. Maintain corrected position
with Gelpy retractor K-wires (Fig. 8–2). Check
position with intraoperative imaging.
• Harvest iliac crest bone graft (ICBG) tricortical graft to
match size of defect. Harvest additional cancellous
bone to supplement tricortical graft.
Figure 8–1
Figure 8–2
CHAPTER 8 DORSAL AND PALMAR OSTEOTOMY 23 ■