What is the step-by-step procedure for removing a distal radius plate, specifically when only the screws can be removed, 3 years after the initial plating?

Procedure for Distal Radius Plate Removal When Only Screws Can Be Removed

For a distal radius plate that cannot be fully removed 3 years after initial implantation, the recommended approach is to remove only the screws and leave the plate in situ, as attempting complete plate removal may cause excessive tissue damage and functional impairment.

Preoperative Planning

• Review previous surgical records and imaging to understand the plate type, screw configuration, and potential reasons for plate adherence
• Obtain current radiographs to assess bone-plate interface and identify any screw loosening
• Ensure appropriate surgical instruments are available, including:
  • Standard screwdrivers matching the original implant system
  • High-speed metal cutting burrs
  • Specialized screw removal sets
  • Fluoroscopy equipment

Step-by-Step Procedure

1. Anesthesia and Positioning

• Perform the procedure under appropriate anesthesia (regional or general)
• Position the patient supine with the affected arm on a radiolucent hand table
• Apply a tourniquet to the upper arm for better visualization

2. Surgical Approach

• Use the same surgical approach as the initial procedure (typically volar Henry approach)
• Make the incision directly over the previous scar
• Carefully dissect through scar tissue to expose the plate and screws
• Identify and protect important structures (median nerve, flexor tendons)

3. Screw Removal

• Identify all screws using fluoroscopy if needed
• Clear debris from screw heads using a small curette
• Ensure screwdriver fits properly into screw head recesses
• Remove screws one by one, starting with the most accessible ones
• For stripped screws:
  • Use a screw extraction set with reverse-threaded bits
  • If unsuccessful, use a high-speed burr to create a slot in the screw head for a flat screwdriver 1

4. Dealing with Cold-Welded Screws

• Cold welding (where screws become fused to the plate) occurs in approximately 22-28% of cases 1
• For cold-welded screws:
  • Apply steady pressure while rotating the screwdriver
  • If unsuccessful, use a high-speed metal cutting burr to cut around the screw head
  • In extreme cases, cut the plate between screw holes to remove sections 2

5. Assessment of Plate Mobility

• After removing all screws, gently attempt to mobilize the plate
• If the plate remains firmly attached to bone:
  • Do not use excessive force as this may fracture the radius
  • Document that the plate could not be safely removed

6. Closure

• Irrigate the wound thoroughly
• Close in layers with attention to the extensor retinaculum
• Apply a compressive dressing and splint

Postoperative Care

• Elevate the extremity for 48-72 hours
• Begin active finger motion exercises immediately to prevent stiffness 3
• Progressive range of motion exercises after the immobilization period 3
• Apply ice during the first 3-5 days for symptomatic relief 3
• Implement a directed home exercise program 3

Common Challenges and Solutions

Plate Adherence Issues

• Bony overgrowth: The most common reason plates cannot be removed after 3 years is bony ingrowth over and around the plate 4
• Solution: If the plate cannot be safely mobilized after screw removal, it is safer to leave it in place than risk fracture or extensive soft tissue damage

Stripped Screw Heads

• Occurs in approximately 8-10% of cases during removal 1
• Solutions:
  • Use specialized extraction sets
  • Create new slots with high-speed burrs
  • In extreme cases, leave the stripped screw in place if it's not causing symptoms

Cold-Welded Hardware

• Occurs in up to 28% of cases 1
• May require cutting the plate and removing it in sections

Important Considerations

• Complete hardware removal is not always possible or necessary
• Leaving a well-fixed plate in situ after screw removal is acceptable if attempts at removal would cause excessive tissue damage
• The incidence of plate removal following distal radius fracture has decreased to approximately 11-12% in recent years 5
• Most plate removals (87.3%) are conducted within the first 2 years after plating 5

Expected Outcomes

• Resolution of symptoms in most cases even with partial hardware removal
• Progressive improvement in wrist function with appropriate rehabilitation
• Low risk of refracture if the plate remains in place