What structures need to be careful of right from the incision during implant removal after distal radius fracture plating?

Critical Structures to Consider During Implant Removal After Distal Radius Fracture Plating

When removing implants after distal radius fracture plating, careful attention must be paid to the extensor tendons, particularly the extensor pollicis longus tendon, which is most vulnerable to irritation or damage from protruding hardware. 1

Anatomical Structures Requiring Careful Attention

Soft Tissue Structures

• Extensor tendons: Particularly vulnerable during dorsal plate removal
  • Extensor pollicis longus (EPL) tendon in the third extensor compartment 1
  • Other extensor tendons in their respective compartments
• Flexor tendons: At risk during volar plate removal
• Median nerve: Can be at risk during volar approach
• Radial artery: Located near the surgical field
• Sensory branches of radial nerve: Superficial and easily damaged

Bony Structures

• Thickness, height, and integrity of facial bone wall 2
• Height and thickness of palatal bone wall 2
• Screw positions: Carefully identify all screws to prevent leaving shanks in situ 1
• Distal radioulnar joint (DRUJ): Maintain alignment and stability 2

Approach-Specific Considerations

Dorsal Approach Removal

• Higher complication rate with dorsal plating
• Main complications requiring removal:
  • Extensor tendon problems
  • Decreased range of motion
  • Dorsal wrist pain syndrome 3
• Carefully elevate extensor tendons to avoid damage

Volar Approach Removal

• Risk of hardware removal is approximately 10-11.2% 4, 5
• Highest risk period is the first year post-surgery (6.2%), decreasing to 1.7% in second year 4
• Main reasons for removal:
  • Tenosynovitis
  • Implant-associated pain
  • Screw protrusion 4
• Plate prominence relative to the critical line is associated with need for removal 5

Surgical Technique Recommendations

1. Preoperative Planning:

   • Review original operative report to confirm all hardware placed
   • Obtain quality radiographs from multiple angles
   • Consider CT scan if screw positions are unclear

2. Intraoperative Approach:

   • Use the same surgical approach as the original procedure
   • Careful soft tissue dissection to identify all hardware
   • Methodical removal of all screws before plate removal
   • Confirm complete hardware removal with intraoperative imaging

3. Post-Removal Management:

   • Begin active finger motion exercises immediately to prevent stiffness 6
   • Consider vitamin C supplementation (500mg daily for 50 days) to prevent complex regional pain syndrome 6
   • Ice application during first 3-5 days for symptomatic relief 6

Pitfalls to Avoid

• Incomplete hardware removal: Can lead to retained screw shanks that may migrate and cause tendon irritation or rupture 1
• Excessive retraction: Can damage tendons or neurovascular structures
• Inadequate visualization: May lead to missed hardware components
• Forceful extraction: Can cause fracture or damage to surrounding structures

By carefully identifying and protecting these critical structures during implant removal after distal radius fracture plating, complications can be minimized and patient outcomes improved.