Surgical Discussion

Patient positioning:  Supine with arm table attachment

Anatomical surgical approach:  E-FCR

The Extended Flexor Carpi Radialis (E-FCR) approach is a technique for the surgical management of complex articular distal radius fractures, facilitating intrafocal reduction of the articular surface together with enhanced surgical exposure of volar marginal fragments. However, the traditional E-FCR approach necessitates brachioradialis tenotomy to release tension on the radial styloid. Whilst effective, the tenotomy of brachioradialis introduces potential surgical morbidity including elbow dysfunction.

In our modified approach to the E-FCR technique, we circumvent the brachioradialis tenotomy, We demonstrate that overcoming the proximal traction exerted by the brachioradialis can also be accomplished through targeted counter-ligamentotaxis applied directly through the proximal carpal row. This novel methodology acts through both the dorsal and volar radiocarpal ligament complexes.

In our specific approach, we applied traction directly through K-wires inserted into the scaphoid and lunate bones. Traction on each of these is achieved using a Hintermann distractor anchored in the distal aspect of the radial diaphysis. By employing differential traction axial along either the radial and ulnar columns, radial inclination can be meticulously adjusted. Similarly, we can manipulate the tilt of the scaphoid and lunate to preferentially tension the dorsal or volar radiocarpal ligament complexes, thereby gaining precise control over the volar tilt of the radial articular surface fragment.

This targeted ligamentotaxis facilitated the reduction of the articular surface despite significant bone loss, as evident in the accompanying images. Our modification preserves the integrity of the brachioradialis while allowing for a finely controlled, polyaxial reduction of radial articular fragments through the direct manipulation of the scaphoid and lunate. The preliminary outcomes suggest an improvement in both clinical and radiological measures, validating the efficacy of this novel approach for managing complex fractures.

Postoperative protocol:   Free A/PROM NWB for 6 weeks

Orthopaedic implants used:   Synthes 2 Column DRP