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Distal Radius Extra-articular Fracture ORIF with Volar Appr

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)
  • radiocarpal instability from release of volar wrist capsule ligaments
  • 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 volar 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, supinate arm
  • arm tourniquet placed on arm with webril underneath (optional)
G

Volar Approach

1

Mark incision

  • make incision along palpable flexor carpi radialis (FCR) tendon sheath
  • make ulnar or radial curve so you don't cross perpendicular to flexion crease

2

Incise skin flaps and subcutaneous fat

  • identify PCBMN

3

Dissect through FCR sheath

  • section fibers of volar FCR tendon sheath in line with tendon
  • retract FCR tendon ulnarly and incise through the dorsal aspect of the FCR sheath
  • can retract FCR radially if carpal tunnel access is necessary
H

Deep Dissection

1

Locate the FCR sheath under the FPL and retract ulnarly

  • after the FPL is bluntly retracted, the pronator quadratus (PQ) is seen
  • be careful of palmar cutaneous branch of median nerve
  • arises 5cm proximal to wrist joint, ulnar to FCR

2

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
  • use bipolar to cauterize branching vessels from radial artery

3

Brachioradialis can be released if needed (optional)

  • removes deforming force
  • dorsal radial sensory nerve branch is deep to brachioradialis
I

Fracture Preparation and Reduction

1

Clear fracture site

  • remove interposing periosteum and hematoma from fracture site
  • use freer elevator to open fracture site
J

Provisional Fixation with K Wires and Plate

1

Reduce fracture

  • apply traction and manipulation of the hand to obtain a reduction
  • further reduction can be performed with direct fragment manipulation
  • place rolled blue towels under dorsal wrist to aid in volar translation or radial/ulnar deviation

2

Place Kwires for provisional fixation

  • if fragment(s) unstable use 1.6mm K-wires
  • from radial styloid proximally across fracture line
K

Definitive Plate and Screw Fixation

1

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
  • hold proximal aspect of plate 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

2

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 with plate location
  • check screw lengths after inserting all distal row locking screws
  • obtain fluoroscopic views to make sure no screw penetration into joint
  • checking a radial inclination view is 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
L

Confirm Alignment and Implant Position

1

Take final fluoroscopic images

  • can compare to pre-op or intraop radiographs of contralateral wrist
N

Wound Closure

1

Irrigation, hemostasis, and drain

  • 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 outcome

2

Closure

  • close 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

3

Dressing and 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 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
 

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