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INDICATIONS

• Type II distal radial shear fractures


o Usually require open reduction and internal fixation
 Barton's fractures are almost impossible to treat by closed means.
 Buttress plate fixation of volar Barton's fractures is usually necessary.
• Type III compression injuries
o Require operative treatment if
 Intraarticular damage is significant
 Radial shortening is severe
o Fixation with multiple Kirschner wires or plates is often necessary, and cancellous
bone grafting is frequently required to fill impacted areas.
o Often a combination of open and closed techniques is necessary to satisfactorily
treat type III fractures.
• Type IV avulsion fractures
o Are usually associated with radiocarpal fracture-dislocations and are therefore
unstable
o Often the avulsed fracture fragments are so small that they can be repaired only
with suture.
o Secure reduction of the carpus to the distal radius can frequently be achieved only
with Kirschner wires.

• Type V high-velocity fractures


o Always unstable, frequently open, and difficult to treat
o A combination of percutaneous pinning and external fixation is often necessary.
 Many of these fractures are so severely comminuted that open reduction is
impossible.

CONTRAINDICATIONS

Severe medical comorbidities that prevent surgery

EQUIPMENT

• Hand tray and hand table


• Small fragment and mini fragment set
• Technique-specific tray, as required

ANATOMY

• The distal radius and ulna may be divided into three distinct columns.
o The lateral and medial columns correspond to the scaphoid facet and lunate
facets, respectively, of the distal radius.
o The medial column is further divided into dorsomedial and volar medial parts.
o The ulnar column consists of the ulnar styloid and triangular fibrocartilage
complex.
 Tears of the triangular fibrocartilage occur when the medial column of the
distal radius, ulnar styloid, or both are intact.
 Distal radioulnar joint instability is associated with significant
displacement of the ulnar styloid.

TECHNIQUES

• Post-Procedure: Distraction Plate Fixation


• Post-Procedure: Volar Buttress Plate Fixation (Ellis)
• Post-Procedure: Volar Plating of Intraarticular Compression Injuries (Medoff)

Post-Procedure: Distraction Plate Fixation

POST-PROCEDURE CARE

• Immediately begin finger and other joint upper extremity exercises.


• If a splint was applied, it should be removed at 3 weeks.
• Percutaneous Kirschner wires should be removed at 6 weeks.
• Activities of daily living are allowed, but lifting should be restricted to 5 lb.
• Once union is achieved, remove the distraction plate and begin range-of-motion
exercises.

COMPLICATIONS

• Median nerve injury


• Reflex sympathetic dystrophy
• Malunion, nonunion
• Tendon rupture
• Infection

ANALYSIS OF RESULTS

Studies have demonstrated a high percentage of good to excellent outcomes for distraction plate
fixation.

OUTCOMES AND EVIDENCE

Ruch et al reported good to excellent outcomes in 90% of 22 patients using this technique.

Procedure: Distraction Plate Fixation

Post-Procedure: Volar Buttress Plate Fixation (Ellis)

POST-PROCEDURE CARE

• Immobilize the wrist and forearm with a plaster sugar tong splint for 2 weeks.
• Next, use a removable ball-peen splint, permitting gentle active exercises two or three
times a day for the next 2 weeks.
• All immobilization is removed at 4 weeks and progressive motion continued until union
is solid.

COMPLICATIONS

• Median nerve injury


• Reflex sympathetic dystrophy
• Malunion, nonunion
• Tendon rupture
• Infection

ANALYSIS OF RESULTS

The use of buttress plating for the treatment of distal radius fractures have proven to yield
excellent results when surgical intervention occurs early and care is used to obtain anatomic
reduction of the fracture.

OUTCOMES AND EVIDENCE

• Smith et al: 100% union rate with 71% excellent, 18% good, and 11% fair results.
• Odumala et al: No difference in development of median nerve symptoms in patients
treated with prophylactic carpal tunnel decompression compared with those without
decompression.

Procedure: Volar Buttress Plate Fixation (Ellis)

Post-Procedure: Volar Plating of Intraarticular Compression Injuries (Medoff)

POST-PROCEDURE CARE

• Keep the extremity elevated at all times until postoperative swelling subsides.
• Beginning on the first postoperative day, remove the splint 2 to 3 times a day for range-
of- motion exercises.
• Allow clerical work at 2 weeks.
• Resistive loading is allowed when signs of radiographic union appear.

COMPLICATIONS

• Median nerve injury


• Reflex sympathetic dystrophy
• Malunion, nonunion
• Tendon rupture
• Infection
ANALYSIS OF RESULTS

Studies have demonstrated a high percentage of good to excellent outcomes for the Medoff
system.

OUTCOMES AND EVIDENCE

Medoff reported 20 good to excellent results in 21 patients with intraarticular comminuted distal
radial fractures treated with the TriMed Wrist Fixation System (TriMed, Valencia, Calif.).

Procedure: Volar Plating of Intraarticular Compression Injuries (Medoff)

PRE-OPERATIVE AND POST OPERATIVE CARE

Care of Pre-operative Patient

Nursing
Nursing Diagnosis Expected Outcome
Intervention
1. Implement pre- & post-op teaching
Patient/parent will
Knowledge deficit program.
verbalize understanding of
R/T pre-op care.
pre- & post-op care.
2. Document response.
1. Remove nail polish, make-up.
2. Bathe and shampoo the night before
Potential infection
surgery.
R/T surgical Infection free post-op.
3. Betadine scrub to surgical area.
procedure.
4. Dress in hospital clothing after scrub.
1. NPO as ordered.
2. Sign at bedside; NPO sticker on patient.
Potential aspiration
R/T general No aspiration. 3. Re-emphasize importance of NPO to
anesthesia. patient and parent; empty water pitcher
and glass from bedside; check crib for
bottles.
1. Explain procedures.
2. Provide time for patient/parent to ask
Potential anxiety
Decreased anxiety. questions, express fears or concerns.
R/T surgery.
3. Offer reassurance.
Potential alteration Normal parameters for 1. Obtain baseline assessment of all systems
of vital functions patient's vital signs & N/V status within 8 hours pre-op.
R/T surgery. established.
2. Assess V.S. within 2 hours pre-op.

Care of Post-operative Patient

Expected
Nursing Diagnosis Nursing Intervention
Outcome
Patient and family will 1. Implement post-operative
Knowledge deficit R/T verbalize and demonstrate teaching program.
post-operative care. understanding of post-
operative care. 2. Document response.
1. Explain procedures.
2. Provide time for questions,
Potential anxiety R/T Patient and family will cope
expression of concerns and
surgery, post-operative effectively with surgical post-
fears.
care. operative process.
3. Offer reassurance.
1. Assess breath sounds-HR/RR at
least q shift.
Potential respiratory
Patient will not experience 2. Turn, cough and deep breathe
compromise R/T general
respiratory compromise. q2 hrs.
anesthesia.
3. Record vital signs.
1. Assess for pain and medicate
Patient will per protocol.
Alteration in comfort R/T
verbalize/demonstrate relief
surgery.
from pain. 2. Reposition for comfort as
ordered/prn.
Potential neurovascular Patient will not experience .
compromise R/T surgical neurovascular compromise
procedure. 1. Assess surgical site or affected
extremity for color, capillary
refill, sensation, temperature,
pulses and active/passive ROM
as ordered.
2. Document neurovascular status
as ordered.
3. Report any neurovascular
compromise to M.D.
4. Position extremity with
elevation if ordered.

5. Apply ice or heat as ordered.


Potential alteration in
Patient will exhibit appropriate
level of consciousness 1. Assess LOC q shift.
LOC.
R/T anesthesia.
1. Monitor I/O q hour with IV or
foley.
2. Begin ice chips or clear liquids
Potential alteration in slowly as ordered.
Patient will have adequate
fluid balance R/T 3. Maintain IV fluids as ordered.
fluid intake and urine output.
surgery. 4. Call M.D. for catheter order if
unable to void after surgery.

5. Assess GU status q shift.


1. Mobilize as ordered.
Potential alteration in 2. Administer laxative of choice or
bowel elimination R/T Patient will have BM by post- suppository for no BM after 3
anesthesia and post- operative day #4. days.
operative immobilization
3. Assess GI status q shift.
Potential alteration in 1. Assess skin q shift.
Patient will not experience
skin integrity R/T
skin breakdown.
immobility. 2. Provide daily nursing care.

Medical Diagnoses: Impaired Physical Mobility, Acute pain, secondary to fractured left
femur, ORIF surgery, Musculosketeal impairment
Assessme Nursing Client Nursing *I Evaluation
nt DX/Clinical Goals/Desired Interventions/Actions/ Goals Interventio
Problem Outcomes/Object Orders and Rationale ns
ives
Subjectiv Problem: Long Term: * Apply any ordered X Goal met. Continue
e brace before Pt was intervention
Impaired Pt will be able to mobilizing the client. able to s as listed.
Pt Physical ambulate around ambulate Encourage
screams Mobility the nurses’ Rationale: around pt to
when station 2X by “Brace support and the continue the
staff discharge. stablilize a body part, nurses’ use of
attempts allowing increased station by braces and
to move mobility.” (Ackley & discharge. assistive
the left Ladwig, 2008, p 552). Pt was devices
lower able to after
extremity *Increase complete discharge
. independence in ADLs his activity until he
more than feels
Pt Rationale: twice. Pt comfortable
demonstr “Providing did not c/o.
ates unnecessary assistance complain Encourage
difficulty with transfers and of any the pt to
with any activities may promote pain or continue his
movemen dependence and a loss discomfort independen
t of the of mobility.” (Ackley & upon ce in ADLs
left lower Ladwig, 2008, p 552). ambulatio and c/o
extremity n. unnecessary
. *Obtain any assistive assistance.
devices needed for Pt states
activity. “I feel like
I’m finally
Rationale: getting
Objective “Assistive devices can back to
help increase my old
Pt states mobility.” (Ackley & self.”
that his Ladwig, 2008, p 552).
pain level R/T: Short Term: X Goal met. Continue
is a 9 on *Assess the pt’s pain Pt able to intervention
a 10 Acute Pt will perform by using the 10 point fully s as listed.
point pain, passive range of pain rating scale q4 hrs complete Continue to
pain secondary motion exercises or PRN. passive assess pain
rating to by the end of this range of using the 10
scale. fractured shift. Rationale: motion point pain
left femur “Single- item ratings of exercises scale q4 hrs
Pt pain intensity are valid with or PRN.
grimaces ORIF and reliable as assistance Continue to
during surgery measures of pain from the provide
any kind intensity.” staff by pain control
of motion Anxiety the end of and treat as
or “The client’s report of this shift. needed.
movemen Musculosk pain is the single most Pt did not
t of his eteal reliable indicator of complain
left lower impairmen pain.” of any
extremity t (Ackley & Ladwig, pain
AEB 2008, p. 604-605). associated
Pt’s with
ORIF Grimacing *Before activity, treat exercise
surgery during pain. session.
movement
or activity Rationale:
“Pain limits mobility
Pt and is often
complaints
about pain
and
discomfort

Pt pain
rating of 9
exacerbated by
out of 10.
movement.” (Ackley &
Ladwig, 2008, p 552).
Surgery
that is 2
days post-
op