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

• Radiological evidence of instability, best analyzed using accident X-ray images, additionally CT in case of intra-articular involvement
• dorsal tilt > 5° or ulnar inclination > 20°, compared to the healthy opposite side
• palmar or dorsal comminution
• dislocated intra-articular fracture with step formation > 2 mm
• radial shortening > 5 mm
• accompanying 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 avoid palmar carpal subluxation.
• dislocated extra-articular fracture with comminution (Smith's fractures)
• Die-punch fractures
• secondary loss of correction after primary repositioning and plaster immobilization

• local or general conditions that surgically or anesthesiologically contraindicate an elective operation or can be improved preoperatively
• insufficient soft tissue coverage in open fracture

• Medical history of the typical clinical presentation:
  Trauma involving the wrist
• classic fracture signs (axial deviation, increased mobility, open fracture, step formation, bone gap, crepitation)
• Exclusion of a median nerve lesion
• radiological detection using X-ray examination of the wrist in AP and lateral views, if necessary CT (fracture analysis, surgical planning)

• no special preparation of the patient necessary
• depending on accompanying circumstances, plannable as outpatient or short inpatient procedure
• Clarification of contraindication for bloodless field (e.g. existing shunt in dialysis)

• Information about the surgical method
• Information about extension procedures such as e.g. external fixator 
• Information about general surgical risks (wound healing disturbance, keloid, infection, hematoma)

Information about specific surgical risks

• Pseudarthrosis 
• Loosening of the osteosynthesis material
• Injury to 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 malalignment
• protracted scar pain (usually subsides after 6 months)
• persistent symptoms
• Revision procedure
• Functional deficit of the wrist/hand
• CRPS (rare)

• Plexus anesthesia
• General anesthesia

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

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

• Before the start of the surgery, the surgeon should check the instrumentation for completeness, especially regarding the choice of the plate and the special instrumentation provided by the manufacturer.
• Recommended is the application of an upper arm tourniquet
• A standard bone sieve for small bones is used
• Indispensable: mobile X-ray device (C-arm)

Postoperative Analgesia

Non-steroidal anti-inflammatory drugs are generally sufficient; if necessary, escalation with opioid-containing analgesics can occur. Follow the link here to PROSPECT (Procedure Specific Postoperative Pain Management)
Follow the link here to the current guideline Treatment of Acute Perioperative and Peritraumatic Pain

Medical Follow-up Care

• 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 checks, elastic compression bandage for a few days (Caution: constriction!)
• suture removal after 14 days
• if necessary, 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 completed wound healing; maximum load only permitted after bony consolidation (6 weeks).

Thromboprophylaxis

• not required

Mobilization

• immediate

Physical Therapy

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

Diet Build-up

• not required

Bowel Regulation

• not required

Inability to Work

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

Metal Removal

• removal of the implant is purely elective, but may be necessary in case of soft tissue irritations, especially tendon irritations, to prevent later rupture
• metal removal should only be performed after 9-12 months