Step-by-Step Procedure for Implant Removal of Distal Ulna Fracture Plating
The implant removal of distal ulna fracture plating requires careful surgical technique to avoid complications and ensure optimal patient outcomes, with the procedure focusing on proper exposure, systematic screw removal, and thorough debridement.
Preoperative Considerations
- Confirm fracture healing with appropriate radiographs (posteroanterior, lateral, and oblique views) before proceeding with implant removal 1
- Review previous surgical records to understand the implant type, size, and configuration
- Ensure availability of appropriate removal instruments, including:
- Screwdrivers matching the screw heads
- Extraction sets for damaged screws
- Power tools and hand instruments
Anesthesia and Positioning
- Position patient supine with arm extended on a hand table
- Apply tourniquet to upper arm (optional but recommended for better visualization)
- Prepare and drape the forearm in sterile fashion, ensuring adequate exposure of the distal ulna
Surgical Procedure
Step 1: Incision and Exposure
- Make incision directly over the previous surgical scar
- Carefully dissect through subcutaneous tissue, identifying and protecting sensory branches of the ulnar nerve
- Identify the plate on the distal ulna, taking care to protect the extensor carpi ulnaris tendon
Step 2: Hardware Identification and Exposure
- Fully expose the plate and all screws
- Clear any soft tissue overgrowth or bony ingrowth covering the implant
- Identify any potential obstacles to hardware removal (bone overgrowth, stripped screws)
Step 3: Systematic Screw Removal
- Begin removing screws systematically, typically starting from one end of the plate
- Use appropriate screwdriver that precisely fits the screw head to avoid stripping
- For difficult screws:
- Apply firm axial pressure while turning counterclockwise
- Consider using extraction devices for stripped screws
- For cold-welded screws, use specialized extraction tools 2
Step 4: Plate Removal
- Once all screws are removed, carefully elevate the plate from the bone
- If the plate is adherent to bone, use a periosteal elevator to gently separate it
- Avoid excessive force that could cause iatrogenic fracture
Step 5: Wound Inspection and Debridement
- Perform thorough irrigation of the surgical site
- Remove any debris or loose fragments
- Inspect the bone for any defects or signs of infection
- Obtain deep tissue samples if infection is suspected 1
Step 6: Wound Closure
- Achieve meticulous hemostasis
- Close the wound in layers:
- Deep fascia with absorbable sutures
- Subcutaneous tissue with fine absorbable sutures
- Skin with non-absorbable sutures or staples
Step 7: Dressing and Immobilization
- Apply sterile dressing
- Consider a simple arm sling for comfort rather than rigid immobilization 3
Potential Complications and Management
Screw breakage: If a screw breaks during removal, options include:
- Leaving the fragment if deeply embedded and asymptomatic
- Using specialized extraction tools for removal
- Trephining around the screw with a hollow drill bit as a last resort
Iatrogenic fracture: Avoid by:
- Using gentle technique
- Ensuring complete screw removal before plate extraction
- Considering prophylactic immobilization for high-risk cases
Infection: Manage with:
- Thorough debridement
- Appropriate antibiotic therapy
- Possible retention of new hardware if needed for stability 1
Postoperative Care
- Early mobilization to prevent stiffness
- Pain management with multimodal approach, considering opioid-sparing protocols 1
- Follow-up radiographs to confirm complete hardware removal
- Gradual return to activities as tolerated
Special Considerations
- For cases with significant soft tissue scarring or adhesions, more extensive dissection may be required
- If there is concern for refracture, consider longer postoperative immobilization
- In cases with previous infection, obtain intraoperative cultures and consider extended antibiotic therapy
By following this systematic approach, implant removal from the distal ulna can be performed safely with minimal complications and optimal functional outcomes.