Perioperative management - Angle-stable palmar plate osteosynthesis of a distal radius fracture on the right

• Radiological evidence of instability, best analyzed using the initial X-rays, with additional CT for intra-articular involvement
• dorsal tilt > 5° or ulnar inclination > 20°, compared to the healthy opposite side
• palmar or dorsal comminution zone
• displaced intra-articular fracture with step-off > 2 mm
• radial shortening > 5 mm
• associated ulna fracture
• severe osteoporosis
• articular rim fractures (dorsal and palmar Barton's fracture)
• fracture with ulno-palmar key fragment (critical corner = palmar lunate facet). This fragment includes the radiolunate ligament, which must be surgically fixed to prevent palmar carpal subluxation.
• displaced extra-articular fracture with comminution zone (Smith's fractures)
• Die-punch fractures
• secondary loss of correction after initial reduction and cast immobilization

• Local or general diseases that surgically or anesthesiologically contraindicate an elective operation or are improvable preoperatively
• Insufficient soft tissue coverage in open fracture

• History of the typical clinic:
  Trauma involving the wrist
• classic fracture signs (axis deviation, excessive mobility, open fracture, step formation, bone gap, crepitation)
• exclusion of a median nerve lesion
• radiological evidence by X-ray examination of the wrist in anteroposterior and lateral views, possibly CT (fracture analysis, surgical planning)

• no special preparation of the patient necessary
• depending on accompanying circumstances, can be planned as an outpatient or short-stay procedure
• clarification of contraindication for bloodlessness (e.g., existing shunt in dialysis)

• Information about the surgical method
• Information about additional procedures such as external fixator
• Information about general surgical risks (wound healing disorder, keloid, infection, hematoma)

Information about specific surgical risks

• Pseudarthrosis
• Loosening of osteosynthesis material
• Injury to the median nerve, palmar branch (direct or as traction injury)
• Tendon injury due to screws that are too long (EPL) or due to friction on the plate (FPL)
• Loss of correction with healing in malposition
• Prolonged scar pain (usually subsides after 6 months)
• Persistent complaints
• Revision surgery
• Functional deficit of wrist/hand
• CRPS (rare)

• Plexus anesthesia
• General anesthesia

• the operating table should be rotated 90° so that the injured extremity points away from the anesthesia equipment
• C-arm is positioned to the hand table with the monitor in the direct line of the surgeon
• Position the patient in a supine position, with the shoulder centered at the edge of the operating table
• Position the hand in supination centered on an X-ray permeable (!) hand table. The forearm is covered with a sterile drape and remains freely movable.
• Application of an upper arm tourniquet

• The surgeon sits at the angle between the patient's body and arm, and the assistant at the angle between the arm and head. The image intensifier arm can thus be moved over the injured extremity from a distal position.
• The instrument nurse positions themselves at the head side of the hand table.

• Before the start of the operation, the surgeon should check the instruments for completeness, particularly regarding the choice of plate and the special instruments provided by the manufacturer.
• It is recommended to apply an upper arm tourniquet
• A standard bone tray for small bones is used
• Essential: mobile X-ray machine (C-arm)

Postoperative Analgesia

Non-steroidal anti-inflammatory drugs are generally sufficient; if necessary, an increase with opioid-containing analgesics can be made. Follow the link to PROSPECT (Procedures Specific Postoperative Pain Management)
Follow the link to the current guideline Treatment of acute perioperative and peritraumatic pain

Medical Follow-up Treatment

• consistent elevation of the surgically treated extremity above heart level to counteract swelling
• if necessary, application of cold packs as a local physical measure
• regular wound inspection, elastic compressive bandage for a few days (Caution: constriction!)
• suture removal after 14 days
• if necessary, use of fatty ointment for scar care (special scar ointment not necessary)
• release of the wrist for performing activities of daily living is possible with sufficient bone quality after wound healing is complete, maximum load is only allowed after bone consolidation (6 weeks).

Thrombosis Prophylaxis

• not required

Mobilization

• immediate

Physical Therapy

• active exercise treatment with possible physiotherapeutic support with full extension and fist closure of the fingers and wrist from the 1st postoperative day (prevents hand edema and finger stiffness).

Dietary Build-up

• not required

Bowel Regulation

• not required

Incapacity for Work

• generally 14-21 days, depending on manual activity (maximum 6 weeks)

Metal Removal

• removal of the implant is purely elective, but may be required in cases of soft tissue irritation, particularly tendon irritation, to prevent a later rupture
• metal removal should only occur after 9-12 months