Pearls & Pitfalls Orthobullets Technique Guides cover information that is "not testable" on ABOS Part I Preparation identify fracture pattern, amount of comminution, and intra-articular extension Positioning supine with shoulder at edge of bed centered on hand table radiolucent hand table with bed turned 90° c-arm perpendicular to bed Approach volar approach to distal radius: flexor carpi radialis (FCR) Reduction reduce fracture using traction and direct manipulation techniques Fixation temporary stabilization with k-wires through radial styloid across fracture site volar locking wrist plate with distal screws into subchondral bone Closure coagulate any bleeders for hemostasis, carefully examine radial artery Postoperative soft dressing, 2 weeks volar slab splint for immobilization postop vitamin C to reduce incidence of CRPS rehabilitation 2 weeks non-weight bearing in splint 4 weeks non-weight bearing in removable wrist splint with range of motion exercises Planning & Preparation Template Fracture identify fracture characteristics distal radius fracture pattern bone quality DRUJ disruption amount of comminution presence of intra-articular extension(s) complex fractures may benefit from pre-operative CT scan compare to contralateral wrist xray for: radial height, inclination, ulnar variance, and volar tilt check radial/ulnar artery patency of operative extremity with Allen’s test Plan Approach plan out volar approach to distal radius may add dorsal approach to wrist as needed Table and Imaging setup OR with standard operating table and radiolucent hand table turn table 90° so that operative extremity points away from anesthesia machines c-arm perpendicular to hand table with monitor in surgeon's direct line of site Equipment & Positioning Potential Hardware Systems precontoured volar locking plate system of choice Patient Position supine with shoulder at edge of bed centered at level of patient’s shoulder, hand centered on hand table, supinate arm arm tourniquet placed on arm with webril underneath (optional) Surgical Technique Approach FCR-based approach to the volar wrist internervous plane is FCR (median nerve) and FPL (AIN) Soft Tissue Dissection incision made along course of FCR tendon incise FCR tendon sheath to allow tendon mobilization retract FCR tendon ulnarly can retract radially if access needed to carpal tunnel sharply incise deep FCR sheath retract underlying FPL in an ulnar direction be careful of palmar cutaneous branch of median nerve arises 5cm proximal to wrist joint, ulnar to FCR visualize the proximal extent of pronator quadratus and take down sharply with knife incise radial and distal borders of quadratus and take down in L-shaped fashion bipolar to cauterize branching vessels from radial artery brachioradialis can be released if needed (optional) removes deforming force dorsal radial sensory nerve branch is deep to brachioradialis Fracture Preparation and Reduction interposing periosteum and hematoma removed from fracture site Freer elevator to open fracture site traction and manipulation of the hand is used intially to obtain a reduction further reduction can be performed with direct fragment manipulation rolled blue towels under dorsal wrist to aid in volar translation or radial/ulnar deviation if fragment(s) unstable use 1.6mm K-wires from radial styloid proximally across fracture line Plate and Screw Fixation distal fixation first after fracture reduction check size, length, and rotation of plate on distal radius use K-wires into plate to temporarily fix distally hold plate down to bone distally K-wires in distal row of plate will show angle/location of distal screws want screws as distal as possible for subchondral bone support proximal aspect of plate held off bone with screw or elevator drill and insert distal row screws fluoro AP and radial inclination view (distal radius angled 20° off of hand table) remove K-wires from distal plate bring plate down to bone proximally and hold with 3 non-locking screws proximal fixation first place cortical screw in proximal oval hole of plate using 3.5mm screw plate can be readjusted later on due to oval hole insert distal ulnar cortical screw after drilling through guide for preliminary fixation or locking screw if confident regarding plate location check screw lengths after inserting all distal row locking screws obtain fluoroscopic views to make sure no screw penetration into joint radial inclination view critical (lateral xray with distal radius lifted 20° off hand table) drill and insert screws into plate shaft proximal to fracture if bony defect, can add auto/allograft bone as needed Confirm Plate & Screw Position take final fluoroscopic images can compare to pre-op or intraop radiographs of contralateral wrist Closure Irrigation & Hemostasis irrigate wounds thoroughly and deflate tourniquet (if utilized) coagulate any bleeders carefully, evaluate for damage to radial artery quadratus can be laid over plate repair of quadratus does not improve outcomes Closure subcutaneous layer with 3-0 absorbable suture 3-0 nylon vertical/horizontal mattress for skin alternatively, can use running 4-0 or 5-0 Monocryl for subcuticular stitch Dressing & Splint incision dressing (gauze, webril) followed by volar slab splint for immobilization allow wrist to rest in neutral position while splint sets post-operative vitamin C 500mg x 50 days to reduce incidence of RSD/CRPS (2010 AAOS Clinical Practice Guidelines) Postoperative Care 2 Weeks wound check and remove sutures remove surgical splint and place in removable splint begin range of motion exercises to wrist and hand 6 Weeks advance weight-bearing status in removable wrist brace advance rehabilitation Complications Complications median nerve neuropathy (carpal tunnel syndrome, 1-30%) superficial and deep infections (1-2%, up to 20% in diabetics, peripheral neuropathy) neurovascular injury (palmar cutaneous branch of median nerve, radial artery) radiocarpal instability from release of volar wrist capsule ligaments wound breakdown screw penetration into joint post-traumatic radiocarpal arthritis malunion and nonunion RSD/CRPS