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 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 B Advanced Evaluation and Management 1 Interpretation of diagnostic studies for fragiity fractures with appropriate management and/or referal 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 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 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 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) G 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 H 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 I Distal Fixator Pins 1 Identify Pin Placement identify the bare area over the proximal third of the second metacarpal 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 J 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 Postoperative Patient Care O 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
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 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 B Advanced Evaluation and Management 1 Interpretation of diagnostic studies for fragiity fractures with appropriate management and/or referal 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 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
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 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) G 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 H 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 I Distal Fixator Pins 1 Identify Pin Placement identify the bare area over the proximal third of the second metacarpal 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 J 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
O 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