Distal Radius Fracture Fixation (ORIF)

Why this approach — at MOS

The volar locking plate is the standard of care for displaced distal radius fractures in active patients, and the technical details of its application determine the outcome. Plate position matters: the plate must sit at or just proximal to the "watershed line" of the distal radius — too far distal and the plate edge contacts the flexor tendons, leading to tendon irritation or eventual rupture. Dr. Fitzgibbons identifies this critical anatomic relationship under fluoroscopy during every case and confirms that distal screws do not penetrate the radiocarpal joint by taking tangential (skyline) views before closing.

Intra-articular fractures with joint surface involvement receive particular attention to the quality of articular reduction. Joint surface step-off greater than 2 mm is associated with significantly higher rates of post-traumatic wrist arthritis in the published literature. For complex intra-articular fragments, wrist arthroscopy can be used concurrently to directly visualize the articular surface and confirm reduction — an advantage over fluoroscopy alone.

Associated injuries are assessed at the time of surgery. TFCC tears, scaphoid fractures, and carpal instability may accompany distal radius fractures and may require concurrent or staged treatment. At Maryland Orthopedic Specialists in Bethesda, we evaluate all distal radius fracture patients for concurrent wrist pathology to avoid missing injuries that could compromise the long-term result.

Timing is critical. We prioritize early surgical consultation for displaced fractures so that fixation can be performed within the optimal 2-week window, before early fracture healing makes reduction more difficult.

Who is a candidate?

Indications

• Displaced distal radius fracture with unacceptable alignment: dorsal angulation greater than 10–20 degrees, radial shortening greater than 3 mm, or intra-articular step-off greater than 2 mm
• Unstable fracture pattern that loses reduction when splinted or casted
• Intra-articular (joint-involving) fractures with displacement of the joint surface
• Open fractures requiring surgical irrigation and stabilization
• Young or active patients whose functional demands require anatomic alignment of the wrist joint
• Fractures associated with carpal instability, scaphoid fracture, or other concurrent wrist injuries
• Elderly patients with high functional demands who require early wrist motion

Contraindications

• Non-displaced or minimally displaced fractures that hold acceptable alignment in a cast
• Elderly, low-demand patients whose functional requirements can be met with cast treatment even if alignment is imperfect
• Severe osteoporosis or bone quality that may not support plate fixation (external fixation or cast may be preferred)
• Active infection at the surgical site
• Significant medical comorbidities that make general or regional anesthesia unsafe

Conservative Treatment First

Many distal radius fractures — particularly those that are non-displaced, minimally angulated, or in elderly, sedentary patients — are treated successfully without surgery. Initial treatment involves a closed reduction in the emergency department or clinic: the fracture is manually realigned under local or regional anesthesia (a hematoma block) and the arm is placed in a sugar-tong splint or short-arm cast. Serial radiographs are taken at 1 week and 2 weeks after reduction to confirm that the bone has not shifted.

If the fracture holds acceptable alignment through the first two weeks in a cast, non-surgical treatment continues for a total of 6 weeks, followed by supervised physical therapy for wrist range of motion and strengthening. If the fracture shifts out of alignment during serial follow-up, surgical fixation is recommended. The 2-week window is important: delaying surgery beyond this point significantly increases the technical difficulty of the procedure. For active patients and those with displaced intra-articular fractures, early surgical planning rather than prolonged cast observation is often the more efficient and reliable path to a good outcome.

The procedure

What Is Distal Radius Fracture Fixation (ORIF)?

Distal radius fracture fixation (ORIF) is surgery to realign and stabilize a broken wrist bone using a metal plate and screws. It is used when the fracture is displaced, unstable, or cannot be held in proper alignment with a cast alone. A volar locking plate is the most commonly used implant.

The distal radius is the larger of the two forearm bones at the wrist. It forms the primary weight-bearing surface of the wrist joint and provides the structural platform on which the hand sits. Distal radius fractures are among the most common fractures treated by orthopedic surgeons — they most frequently occur when a person falls onto an outstretched hand, though high-energy mechanisms such as motor vehicle accidents and sports injuries also cause them. The classic "Colles fracture" refers to a distal radius fracture with dorsal (backward) displacement of the broken fragment.

Not every distal radius fracture needs surgery. Fractures that are minimally displaced and stable can be treated effectively with a cast for 6 weeks, followed by physical therapy. Surgery becomes the appropriate recommendation when the fracture is significantly displaced, the joint surface (articular surface) is stepped or gapped, the fracture is unstable (it shifts when splinted), or when the patient's functional demands require a precise anatomic reduction — particularly in younger, active patients and manual workers.

The preferred surgical implant is a volar locking plate — a low-profile titanium plate applied to the palm side of the radius. The plate is held in place by locking screws that engage both the plate and the bone, creating a fixed-angle construct that holds the fracture reduced even in osteoporotic bone. This implant design, refined over the past two decades, has largely replaced external fixation and dorsal plating as the standard of care for most displaced distal radius fractures. Surgery should ideally be performed within 2 weeks of the fracture — after this window, soft-tissue swelling and early callus formation make reduction more difficult.

What Happens During Distal Radius Fracture ORIF?

Setting and anesthesia: The procedure is performed at an ambulatory surgery center. Regional anesthesia (a brachial plexus nerve block that numbs the entire arm) is most commonly used, with sedation for comfort. General anesthesia is available for patients who prefer it or when regional anesthesia is not appropriate. The procedure takes 60–90 minutes.

Positioning: You lie on your back with the arm extended on a hand table. A tourniquet is applied to the upper arm. The wrist is cleaned and sterile draped.

Fracture reduction: The surgeon makes a 4–6 cm incision on the palm side of the wrist, in a skin crease between the flexor carpi radialis tendon and the radial artery. The pronator quadratus muscle is elevated off the distal radius, exposing the fracture. The fracture fragments are reduced — repositioned to their correct anatomic alignment — under direct vision, often assisted by fluoroscopic (live X-ray) imaging in the operating room. Reduction is confirmed on the monitor before any implant is placed.

Plate application: A volar locking plate is positioned against the volar (palm-side) surface of the distal radius. The plate is secured proximally with standard cortical screws in the shaft. Distally, locking screws are placed through the plate into the distal fragment, capturing the subchondral bone just beneath the wrist joint surface. The locking mechanism means each screw locks into the plate at a fixed angle — creating a stable construct that prevents the distal fragment from collapsing back into the malreduced position. Fluoroscopic images are taken in multiple views to confirm screw length, plate position, and fracture reduction. No screw should penetrate the wrist joint.

Closure: The pronator quadratus muscle is repaired over the plate to protect the flexor tendons from the plate's edge. The incision is closed in layers and a volar splint is applied with the wrist in neutral position.

Recovery room: Pain is typically well-controlled with the regional nerve block, which may last 12–18 hours. You are discharged home the same day with oral pain medication, a splint, and clear elevation instructions.

Recovery timeline

Frequently Asked Questions