Step-by-Step Procedure for Implant Plate Removal from Old Second Metacarpal Fracture
The removal of an implant plate from a healed second metacarpal fracture requires careful surgical technique to minimize complications and optimize patient outcomes.
Preoperative Planning
- Review previous surgical records and imaging to understand the exact plate type, size, and screw configuration
- Obtain current radiographs to confirm complete fracture healing
- Ensure all necessary equipment is available, including:
- Standard hand surgery set
- Screwdriver sets matching the original implant
- High-speed metal cutting burrs
- Screw removal sets for stripped or cold-welded screws 1
- Fluoroscopy equipment
Surgical Procedure
1. Patient Positioning and Preparation
- Position patient supine with the affected hand on a hand table
- Apply tourniquet to the upper arm
- Prepare and drape the hand in standard sterile fashion
- Inflate tourniquet to 250 mmHg
2. Surgical Approach
- Make an incision along the previous surgical scar on the dorsal aspect of the second metacarpal
- Carefully dissect through subcutaneous tissue, identifying and protecting the extensor tendons
- Retract the extensor tendons to expose the plate on the dorsal surface of the metacarpal
3. Implant Exposure and Assessment
- Completely expose the plate and all screws
- Remove any fibrous tissue overlying the plate and screw heads
- Identify any cold-welded or damaged screws that may require special removal techniques
4. Screw Removal
- Begin with the most accessible screws, typically at the ends of the plate
- Use the appropriate screwdriver that matches the original implant system
- Remove screws one by one, maintaining plate stability until the final screws are removed
- For cold-welded or stripped screws:
- Use specialized screw removal instruments
- Consider high-speed metal cutting burrs to create a slot in the screw head 1
- In difficult cases, use conical extraction devices designed for stripped screws
5. Plate Removal
- Once all screws are removed, carefully elevate the plate from the bone surface
- Use a periosteal elevator to gently separate the plate from any adherent tissue
- Avoid excessive force that could damage the surrounding soft tissues or fracture the bone
6. Wound Inspection and Closure
- Irrigate the wound with sterile saline solution to prevent infection 2
- Inspect the bone for any defects or areas of weakness
- Ensure complete hemostasis
- Close the wound in layers:
- Repair the extensor mechanism if disturbed
- Close subcutaneous tissue with absorbable sutures
- Close skin with non-absorbable monofilament sutures
7. Post-Procedure Care
- Apply a sterile dressing and a volar splint in functional position
- Elevate the hand to reduce swelling
- Begin early finger range of motion exercises as tolerated
- Remove sutures after 10-14 days
Potential Complications and Management
- Cold-welded screws: Occurs in approximately 22% of cases 1. Have specialized extraction equipment ready.
- Refracture: Risk is higher with comminuted original fractures 3. Consider a period of protected activity following plate removal.
- Extensor tendon irritation: Common indication for plate removal in metacarpal fractures 4. Careful soft tissue handling during removal is essential.
- Infection: Follow proper infection prevention protocols. Consider perioperative antibiotics for prophylaxis 5.
Special Considerations
- Plates positioned close to the metacarpophalangeal or carpometacarpal joints are associated with higher rates of required removal due to tendon irritation 4
- The 3-dimensional lower-profile plates may cause less soft tissue irritation than traditional 2-dimensional plates 6
- Consider the timing of plate removal - typically performed after complete radiographic healing, usually 6-12 months after the initial surgery
Follow-up Care
- First follow-up at 2 weeks for suture removal and wound check
- Progressive return to activities based on comfort and healing
- Final follow-up at 6 weeks to ensure complete recovery
By following this systematic approach, the surgeon can safely remove the implant plate from a healed second metacarpal fracture while minimizing complications and optimizing functional outcomes.