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
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)
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