Case Study: Open Reduction and Internal Fixation
of the right distal radius with plating in a 38 year-old patient
Open reduction surgery will often be needed to repair distal fibular fractures, however conservative therapy can be used successfully in stable, minimally displaced fractures. Additional management is necessary if the fracture is open to lower the risk of contamination and infection.
A 38-year-old patient was in our office with complaints of right wrist pain. She went on her son’s hoverboard and fell on her right wrist. She went to Peconic Bay ED where x-rays were taken and wrapped it with an ace bandage. The pain is severe. The quality of the pain is sharp and throbbing. She is icing. Nothing is making the pain better or worse at this point in time.
She got a long-arm splint. She was advised to be treated surgically. She came to the hospital today because she was not able to tolerate the pain. X-ray and CT scans were done which showed displaced intra articular comminuted fracture of distal radius. I met the patient and examined her and discussed the treatment options.
We discussed surgical and nonsurgical management. The patient opted for surgical management. We discussed risks and benefits and complications including infection, bleeding, injury to adjacent nerves and vessels, numbness, implant and fracture failure, need for repeat surgery, need for rehabilitation, wrist pain, and wrist arthritis in the future among others.
He also discussed systemic complications including blood clot, cardiac, pulmonary, and neurologic complications including death. The patient understood and signed an informed consent. The patient was on Suboxone and we also discussed the inability to give her pain medications.
We discussed that we will be using Toradol for her pain control. We also discussed anesthesia for supraclavicular blocks. The patient understood regarding the pain management also and she will be reaching out to her pain doctor for any further recommendations.
The patient was taken to the operating room where she was placed on a well-padded operating table. General anesthesia was induced after giving a supraclavicular block. The patient was put in supine position.
The right upper extremity was prepped and draped aseptically in the usual fashion after application of tourniquet. Volar incision was planned. A mini C-arm was brought in for fluoroscopic guidance.
A volar incision was driven over the flexor carpi radialis tendon. Further incision was made through the skin and subcutaneous tissue. Anterior tendon sheath was cut. Hemostasis was achieved.
The flexor carpi radialis was retracted medially and the posterior sheath was cut in line of the incision again. Pronator quadratus was reached. The pronator quadratus was cut with the use of Bovie along the radial border. The muscle was erased radially and ulnarly to expose the fracture in the distal radius.
The fracture was found to be displaced. Manipulation and reduction of sites were achieved. Volar plate was put onto the distal radius and found to be in acceptable position after application of olive wires. The proximal part of the plate was fixed to the distal radius with the use of particles too.
The distal radius was fixed initially with long particles too which helped to pull the distal fragment onto the plate. After this, the fixation of the plate was done to the distal radius with the use of locking screws distally and nonlocking screws proximally.
The cortical screws distally were exchanged with the locking screw. Final fixation was achieved with the use of four locking screws distally and three nonlocking screws proximally. Rotational fluoroscopy showed good reduction and fixation. Pictures were saved.
The wound was thoroughly irrigated and drained. The ulnar head but the radioulnar joint was well reduced. Decision was made nothing to do for that. Closure was done in layers using #2-0 Vicryl, # 3-0 Monocryl, and #4-0 Monocryl.
Dermabond was used for dressing. A 4 x 4 Webril was applied. A posterior long-arm splint was applied in full supination and Ace wrap was applied. The patient was extubated and moved to recovery in a stable condition.
The patient was seen for post operative check up. We have decided to do formal physical therapy as well as a home exercise program for rehabilitation of the wrist. Patients regularly followed an office visit every 3-4 weeks.
Patient did well after the surgery and continued physical therapy. Patient checked in for a follow up visit after a month and saw significant improvement on her wrist.
Disclaimer – Patient’s name, age, sex, dates, events have been changed or modified to protect patient privacy.
I am Vedant Vaksha, Fellowship trained Spine, Sports and Arthroscopic Surgeon at Complete Orthopedics. I take care of patients with ailments of the neck, back, shoulder, knee, elbow and ankle. I personally approve this content and have written most of it myself.
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