Peggers’ Super Summary of Distal Radius Fracture Fixation
Indications:
 Displaced, irreducible extra-articular #
 Unstable # i.e. volar bartons or dorsal comminution
or angulation
 Intra-articular # with > 2mm step
 Shortening
 Dipunch injury in lunate fossa
Anatomy:
OSSEOUS 11+12=23
 110 PALMAR tilt (0 = acceptable)
 12mm of radial length (-2mm = acceptable)
 230 radial inclination (100 = acceptable)
 Intraarticular step 2mm acceptable
VOLAR
 Henry’s approach distally from the radial styloid
 Longitudinal incision over FCR plane between FRC
and mobile wod
 Base is the radial artery which is retracted radially
DORSAL
 Longitudinal incision ulnar side to Lister’s tubercle
 EPL is identified just ulnar side to the tubercle
 Superficial radial nerve is on the radial side of the
flap, approach with blunt dissection on this side
COMPARTMENTS
 1ST – abductor pollicis brevis & EPB
 2nd – ECRL & B
 3rd – EPL
 4th – EC & Extensor indicis
 5th – ECU
 6th – EDM
Preoperative planning
 Deciding if dorsal approach is necessary
o Large dorsal of middle column fragment
 If median nerve symptoms requires carpal tunnel
decompression
Equipment:
 AO small fragment set
 Plating set available i.e. DVR (distal volar radius
from Dupey) or (Pi-plate dorsally)
 II
 Hand table
 Tourniquet
 Lead hand
Operative room planning:
INTRODUCTION
 Confirm Consent / Mark / WHO form / Abx at
induction
POSITIONING
 Supine with arm supinated and abducted over
radiolucent table
DRAPING
 Antiseptic solution up to elbow
 U drape or perforated hole drape
REDUCTION
 Dorsal translation and angulation and corrected with
a rolled towel under the ulnar boarder of the wrist
 Hand traction followed by translation of the hand in a
palmar direction compared to the forearm
 Pronation of the hand is finally achieved to correct
supination deformity
Surgical approach:
VOLAR
 A distal Henry’s approach over FCR
 The FCR sheath is excised on the volar aspect and
then the tendon is retracted ulnarly
 Beneath is FPL which is too retracted ulnarly
 The radial artery is retracted radially
 Pronator Quadratus is incised by a upside down ‘L’
pointing ulnarly
 A forceps in the joint can highlight the distal radius
EXTENSION TO RELEASE CARPAL TUNNEL
 At the distal part of Henry’s approach draw a
horizontal zigzag to align with the ulnar aspect of
Palmaris longus to release the carpal tunnel
 Layers
o Skin
o Subcutaneous tissue & fat
o Palmar aponeurosis
o Ulnar side muscle Palmaris brevis
o Radial side muscle abductor pollicis brevis
o Transverse carpal ligament
DORSAL
 5-6 cm longitudinal incision centred over the ulnar
side of Lister’s tubercle
 EPL can be seen (3rd compartment) dissect from from
3rd compartment in its entirety
 Sharp dissection of the ulnar side of the tubercle and
blunt dissection to the radial side (avoiding SRN)
 Dissect off 2nd and 4th compartments (as well as the
3rd)
 Transverse arthrotomy can held guide # reduction
under direct vision
RETRACTORS
 Self retainers
 Langerbeck
 Lead hand
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Peggers’ Super Summary of Distal Radius Fracture Fixation
Implant positioning:
 K wire stabilisation +/- small dorsal incision and the
use periodontal elevator can help reduce the dorsal
fragments
 Position the volar or dorsal prosthesis in the desired
position and hold with k wire +/- reduction tool
 Depuy plate use ulnar side K wire in proximal hole
and on plate shaft to check position
o Ulnar K wire assess if screws will be intraarticular
 Place cortical screw in sliding hole
o 12mm in females
o 14mm in males
 Use cortical screw in ulnar side of distal plate to snug
plate to volar surface
 Use smooth peg screws for the rest of the holes
o Females 20-22mm
o Males 22-24mm
 Intra-articular fragment need to rigidly fixed
o Radial styloid
o Dorsal and volar lunate fragments
 Screws should be 33mm from joint for maximum
fixation strength
 Screws should not protrude dorsally. Listers
tubercle may make them appear not too but the sulcus
of the extensor tendons are deeper than the tubercle
 Check supination and pronation as some
screws/plates can abut the DRUJ
 Test TFCC by ulna bone mobility between ulnar
and radial deviation of wrist
o If unstable place 2mm k wires across DRUJ
joint from ulnarly to radially (remove at 4-6
weeks)
 Obtain lateral, oblique and AP final pictures to
confirm screws are not into the joint
 Elevation of joint by 110 aids IA joint assessment
Closure
 Irrigate
 Haemostasis (release tourniquet at the end)
 3/0 vicryl or PDS to subcutaneous tissue and then 4/0
subcuticular caprosyn.
 Older patients cast for 2 weeks until clinic then
removal for x ray and starting Rom exercises
Operative note:
Preparation and Position:
Supine, block, full sterile prep and drape, tourniquet
1HR2mins 250mmHg, WHO checks , iv ANTIBIOTICS
Incision and Approach :
Henry’s approach to the distal radius through bed of FCR,
retracting FCR and FPL radially
Neurovascular bundle protected.
Findings :
2 part fracture, pronator quadratus was mostly ruptured, due to
fracture fragments
Procedure :
Pronator quadratus elevated from the lateral side, # exposed , #
Reduced & DVR depuy locking plate held in place with kwire whilst screws inserted, II check satisfactory – no screws
in joint or protruding, Wrist ROM – full & No displacement of
the fracture seen or felt.
DRUJ / TFCC exam
Closure :
Wound closed in layers – 4/0 vicryl to re-oppose Pr
Quadratus, fat and also subcuticular. Opsite Dressing, wool,
volar slab and crepe
Post Op Instructions :
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Elevate wrist in a sling
Monitor CSM (colour / sensation / movement)
Analgesics
Encourage active finger movements
Plaster room wound check 10 days, then after to wear
bandage not a cast
Clinic 4 weeks for RHSC hand team
No load bearing at least 6 weeks
Evidence:

OA frequencies Knirk & Jupiter 1986. > 2mm step
100% OA, no incongruity 11% OA risk. Di-punch
75% risk of OA
Complications:
Early
 Infection
 Median neuropathy
 Tendon injury
Delayed
 Failure of fixation
 Non-union / Mal-union
Late
 Arthritis
 CRPS type 1
 Tendon rupture
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