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Distal Radius Fracture Spanning External Fixator

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

  • spanning external fixator set

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, supinate arm
  • arm tourniquet placed on arm with webril underneath (optional)

Technique

D

Closed Reduction

1

Perform reduction

  • use manipulation with traction and countertraction
  • shake hand of the manipulated wrist and manipulate wrist using three point bending principles
E

Proximal Fixator Pins

1

Locate pin placement

  • identify radius 10cm proximal to the radial styloid
  • can also be at least 5cm outside the zone of injury
  • look for the bare area that is located in the palpable interval between the brachioradialis and the ECRL muscles

2

Make small incisions at pin sites

  • be sure to protect the branches of the superficial radial and lateral antebrachial cutaneous nerves
  • damage to these nerves can cause a painful neuroma

3

Place proximal pins at a 45 degree angle to the long axis of the arm

  • place pins in the dorsal radial to ulnar volar direction
  • visualize the periosteum
  • drill holes
  • place half pins
  • use a fixator clamp after the placement of the first half pin to determine the placement of the second half pin

4

Check the placement and depth of the pins with fluoroscopy

F

Distal Fixator Pins

1

Identify Pin Placement

  • identify the bare area over the proximal third of the second metatarsal
  • palpate the bare area between the the first dorsal interosseous muscle and the extensor tendon to the index finger
  • place both pins in the proximal 60% of the metacarpal
  • this is to avoid encroaching on the metacarpophalangeal joint capsule

2

Place half pins

  • place the 3 mm half pins in the center of the metacarpal shaft
  • insert the fixator clamp to guide the placement of the distal pin

3

Check pin placement with fluoroscopy

  • be sure the threads of the half pins are fully threaded in the far cortex
G

External Fixator Assembly

1

Close skin without tension

  • use 3-0 nylon to close skin

2

Apply rod connectors

  • apply pin to rod connectors
  • place clamps one fingerbreadth away from skin
  • make sure thumb and wrist motion are not blocked

3

Connect rods

  • connect rod proximally first
  • secure the rod distally
  • place second rod to increase stiffness of overall frame

4

Check reduction with fluoroscopy

5

Lock clamps in place

6

Perform a final tightening

7

Dress Pin Sites

  • place petroleum gauze and bulky dressing

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
  • superficial and deep infections (1-2%, up to 20% in diabetics, peripheral neuropathy)
  • neurovascular injury (lateral antebrachial cutaneous and superficial radial nerve)
  • wound breakdown
  • stiffness
  • malunion and nonunion
  • RSD/CRPS
L

Perioperative Inpatient Management

1

Discharge the patient appropriatlely

  • radiographs in post op
  • schedule follow up
  • oral pain meds
  • wound care
  • clean pin sites
  • prescribe outpatient physical therapy
  • non-weightbearing
  • work on finger, elbow and shoulder ROM
  • making a full fist is big predictor of outcome
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

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
  • start formal PT
  • continue non-weightbearing
  • postop: 6 weeks
  • check radiographs for union
  • remove external fixator and pins under local anesthesia in the office
  • postop: 1 year postoperative visit
N

Advanced Evaluation and Management

1

Interpretation of diagnostic studies for fragiity fractures with appropriate management and/or referal

 

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