Step-by-Step Procedure for Implant Removal After Distal Radius Fracture Plating
The procedure for implant removal after distal radius fracture plating should follow a systematic approach to minimize complications such as screw retention, tendon irritation, or cortical penetration. 1
Pre-Operative Considerations
Imaging Assessment:
Patient Evaluation:
- Assess for symptoms that may indicate hardware complications (pain, limited range of motion, tendon irritation)
- Review the original surgical records to understand plate type and positioning
- Note that approximately 31.3% of patients with volar locking plates undergo implant removal, with an average time to removal of 12.1 months 3
Surgical Procedure
1. Anesthesia and Positioning
- Position patient supine with arm extended on a hand table
- Apply tourniquet to the upper arm
- Prepare and drape the surgical site using standard sterile technique
2. Surgical Approach
- Make an incision along the previous surgical scar
- For volar plates:
- Use the interval between the flexor carpi radialis and radial artery
- Carefully retract the flexor tendons to expose the plate
- For dorsal plates:
- Use the appropriate extensor compartment approach based on plate location
- Take care to protect the extensor tendons, particularly the extensor pollicis longus
3. Hardware Identification and Removal
- Identify all hardware components (plate and screws)
- Remove all screws methodically:
- Begin with distal screws (locking screws first if applicable)
- Then remove proximal screws
- Use appropriate screwdriver size to prevent stripping
- Maintain careful count of all screws removed and compare with the original operative report
- Remove the plate after all screws are extracted
- Thoroughly inspect the surgical site to ensure complete hardware removal
4. Wound Inspection and Closure
- Irrigate the wound
- Assess for any tendon damage or irritation
- Perform range of motion to ensure no mechanical restrictions
- Close the wound in layers
- Apply sterile dressing and splint as needed
Post-Operative Management
Immobilization:
Rehabilitation:
- Begin directed home exercise program including active motion exercises to prevent stiffness 2
- Progress to strengthening exercises as tolerated
Follow-up:
- Schedule follow-up at 2 weeks for wound check and suture removal
- Additional follow-up at 6 weeks to assess function
Potential Complications and Prevention
- Screw Retention: Carefully account for all screws during removal to prevent retained hardware 1
- Tendon Irritation/Rupture: Particularly concerning for dorsal screw penetration into extensor compartments 1
- Re-fracture: Avoid excessive force during hardware removal
- Wound Complications: Ensure meticulous wound closure and post-operative care
Outcomes and Expectations
- Patient satisfaction typically improves after implant removal, with 93% of patients reporting they would choose removal again 3
- Most patients (90%) experience no complications after hardware removal 3
- Range of motion typically improves following hardware removal, with expected values approaching: wrist flexion 46°, extension 50°, pronation 79°, and supination 77° 4
Special Considerations for Long-Term Implants (10 years)
- Assess for possible screw-bone integration that may complicate removal
- Be prepared for potential screw breakage due to long-term implantation
- Have appropriate equipment available for difficult screw removal (e.g., screw extractors, high-speed burrs)
- Consider the possibility of cortical thinning or osteopenia under the plate