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Distal Radius Intraarticular Fracture ORIF with Dorsal Approach

Planning

B

Preoperative Plan

1

Identify fracture characteristics

  • distal radius fracture pattern
  • bone quality
  • DRUJ disruption
  • amount of comminution
  • presence of intra-articular extension(s)

2

Execute surgical walkthrough

  • describe key steps of the procedure to the attending verbally prior to the start of the case
  • describe potential complications and steps to avoid them
C

Room Preparation

1

Surgical instrumentation

  • ensure precontoured dorsal locking plate system of choice is present in the room

2

Room setup and equipment

  • 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

3

Patient positioning

  • supine with shoulder at edge of bed centered at level of patient’s shoulder
  • hand centered on hand table, pronate arm
  • arm tourniquet placed on arm with webril underneath (optional)

Technique

D

Dorsal Approach

1

Mark out the anatomy

  • mark out the anatomy of the distal radius

2

Make the incision

  • make a longitudinal incision 8 to 10 cm long on the dorsal aspect of the wrist just ulnar to Lister`s tubercle

3

Dissect through the subcutaneous tissue

  • carry the dissection down through the subcutaneous tissue
  • be careful to take care of the small cutaneous nerve branches

4

Incise skin flaps and subcutaneous fat

  • dissect down to the extensor retinaculum
E

Deep Dissection

1

Expose the EPL

  • identify the third dorsal compartment
  • make an incision in the third dorsal extensor compartment
  • incise the extensor retinaculum just ulnar to Lister`s tubercle
  • retract the EPL radially

2

Identify the fourth dorsal compartment

  • subperiosteally elevate the fourth compartment and retract ulnarly
  • be careful to avoid entering the fourth compartment

3

Expose the dorsal cortex of the distal radius

4

Expose the articular surface

  • make a longitudinal incision through the dorsal capsule /dorsal radiocarpal ligament
  • this gives exposure to the proximal row and the articular surface of the distal radius

5

Place mini Hohmann retractors to keep visualization

F

Fracture Preparation

1

Remove Lister`s tubercle

  • use a rongeur to remove Lister`s tubercle as it is almost always involved in the fracture

2

Free the fracture fragments

  • remove the fracture hematoma
  • mobilize the fracture fragments with a freer elevator
  • these are often impacted

3

Debride the fragments

G

Fracture Reduction and Provisional Fixation

1

Reduce the articular surface

2

Reduce the radial styloid fracture fragment

  • this is done by traction that is placed along the thumb or the index finger and long fingers

3

Place Kwires for provisional fixation

  • if fragment(s) unstable use 0.062 inch K-wires
  • place the radial styloid K wire obliquely starting at the tip of the radial styloid
H

Final Fixation

1

Place the plate

  • place the plate directly on the shaft of the radius

2

Secure the plate

  • place a bicortical screw in the oval sliding hole of the plate

3

Confirm plate placement and fracture reduction with fluoroscopy

4

Secure the plate distal fragment

  • secure the plate to the distal fragment using one or two cancellous screws
  • try to avoid placing the distal ulnar screw due to possible irritation of extensor tendons of the fourth compartment

5

Add screws

  • add cortical screws to the radius shaft

6

Confirm placement and reduction using fluoroscopy

I

Wound Closure

1

Irrigation and hemostasis

  • copiously irrigate the wound

2

Deep closure

  • use 0-vicryl to close the retinaculum deep to the transposed EPL
  • incorporate the periosteum that forms the floor of the extensor compartment

3

Superficial layer

  • use 3-0 vicryl to close the subcutaneous tissue
  • use 3-0 monocryl on skin

4

Immobilization

  • place in volar splint

Patient Care

K

Preoperative H & P

1

Perform history and physical exam

  • check radial/ulnar artery patency of operative extremity with Allen’s test

2

Orders and interprets basic imaging studies

  • need biplanar films of wrist
  • compare to contralateral wrist xray for
  • radial height, inclination, ulnar variance, and volar tilt
  • metaphyseal comminution
  • volar/ dorsal Barton's
  • die-punch pattern
  • multiple articular parts

3

Splint fracture appropriately

  • place in sugartong splint

4

Perform operative consent

  • describe complications of surgery including
  • 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)
  • wound breakdown
  • screw penetration into joint
  • post-traumatic radiocarpal arthritis
  • malunion and nonunion
  • RSD/CRPS
L

Perioperative Inpatient Management

1

Discharges patient appropriately

  • pain meds
  • wound care
  • do not remove splint until follow up appointment in 2 weeks
  • prescribe outpatient physical therapy
  • non-weightbearing
M

Outpatient Evaluation and Management

1

Perform focused history and physical exam

  • recognizes implications of soft tissue injury
  • open fracture
  • median nerve dysfunction
  • DRUJ instability
  • check radial/ulnar artery patency of operative extremity with Allen’s test

2

Orders/ interprets advanced imaging:

  • CT scan
  • CT for comminuted articular fractures
  • recognize stable and unstable fractures

3

Makes informed decision to proceed with operative treatment

  • describes accepted indications and contraindications for surgical intervention
  • surgical indications
  • median nerve dysfunction
  • instability
  • articular step off/gap
  • dorsal angulation
  • radius shortening

4

Perform a closed reduction and splint appropriately

  • place in sugartong splint after reduction

5

Recognition/ eval fragility fx

  • orders appropriate work-up and/or consult

6

Modify and adjust post-op plan when indicated

  • postop: 2-3 week postoperative visit
  • wound check and remove sutures
  • diagnose and management of early complications
  • remove surgical splint and place in removable splint
  • begin range of motion exercises to wrist and hand
  • continue non-weightbearing
  • postop: 6 weeks
  • advance weight-bearing status in removable wrist brace
  • advance rehabilitation
  • postop: 1 year postoperative visit
N

Advanced Evaluation and Management

1

Interpretation of diagnostic studies for fragility fractures with appropriate management and/or referral

 

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