Preoperative Patient Care A 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 B Advanced Evaluation and Management 1 Interpretation of diagnostic studies for fragility fractures with appropriate management and/or referral C 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 Operative Techniques E 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 F 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) G 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 H 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 I 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 J 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 K 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 L 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 Postoperative Patient Care O 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
A 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 B Advanced Evaluation and Management 1 Interpretation of diagnostic studies for fragility fractures with appropriate management and/or referral C 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
E 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 F 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) G 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 H 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 I 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 J 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 K 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 L 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
O 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