Case 1. A sixty-three-year-old woman sustained a closed distal radial fracture after a fall. Attempted closed reduction was unacceptable, and the patient elected to proceed with open reduction and internal fixation. Fixation consisted of open reduction and application of a Distal Volar Radius (DVR) plate (Hand Innovations, Miami, Florida) with use of intraoperative fluoroscopy.
The first formal radiographs were obtained at two-week follow-up in the office showing three retained drill guides. The patient was offered surgery to remove the guides but declined. By six weeks after the operation, she had attained full range of motion of the wrist and had returned to work with no pain.
Nine months postoperatively, she presented with a spontaneous rupture of the flexor digitorum profundus tendon to the index finger. Radiographs revealed a healed fracture in anatomic alignment. Intraoperatively, the tendon was found to have a near complete laceration directly over the distal aspect of the DVR plate. The patient underwent successful primary repair of the tendon and removal of the hardware. At the time of the one-year follow-up, she had full range of motion of the wrist and had regained full range of motion of the distal interphalangeal joint of the index finger.
Case 2. A forty-eight-year-old woman fell on ice and sustained a closed extra-articular distal radial fracture with 40° of dorsal angulation and dorsal comminution. She underwent open reduction and internal fixation with a DVR locking plate. The proximal row of the DVR plate was filled with locking screws and the distal row was not used. Intraoperative fluoroscopy was employed but was discontinued after placement of the screws. Postoperative radiographs showed retained angled drill guides (Fig. 2).
The radiographs were shown to the patient, who was given the option of immediate return to the operating room or removal of the plate and drill guides at three months. The patient declined further surgical treatment at that time. After three months, with fracture-healing confirmed, the plate and drill guides were removed without incident. No tendon ruptures were observed. At the time of the one-year follow-up, she had full range of motion of the wrist and had returned to work without difficulty.
Case 3. A seventy-nine-year-old woman sustained a predominantly transverse, comminuted, and impacted intra-articular distal radial fracture with mild dorsal angulation. The patient also had a mildly distracted fracture of the ulnar styloid process. Open reduction and internal fixation of the radius was performed, and the fracture was stabilized with a DVR locking plate and screws. Three locking screws were placed distally, and three nonlocking screws were placed proximally. Intraoperative fluoroscopy was used throughout the operation to verify that all distal locking screws were clearly not within the radiocarpal joint. Radiographs obtained in the recovery room immediately after surgery showed a single retained angled drill guide.
We discussed the complication and explained the radiographs to the patient, who elected to forego immediate return to the operating room for guide removal. Fifteen months after surgery, with the locking plate and drill guide still in place, the patient had 45° of extension and 35° of flexion at the wrist. She had not experienced any tendon complications.
Volar locking plates have revolutionized the care of distal radial fractures7-12. The cases of our three patients represent a potential pitfall associated with one type of locking plate, in addition to the pitfalls already reported13-16. Preloading the plate with angled drill guides allows for quick insertion of the locking screws. However, if not all of the potential holes are filled with a screw, care must be taken to remove the drill guides before closure. Because this complication occurred on three separate occasions and affected the patients of three different surgeons, it is unlikely to be due to simple error and represents a small risk that is associated with such newer implant designs. These three surgeons collectively repaired 131 distal radial fractures with this plate design during the same time period. Thus, while the rate of retention (2.3%) is low, additional routine checks must be performed to prevent the complication of retained angled drill guides.
In the first two of our three patients, the event may have been avoided by making postoperative radiographs prior to leaving the operating room. However, this practice has become rarer as operating-room time has become tighter and cost-control pressures on surgeons have increased. The ability to record fluoroscopy films in the digital film library has further decreased the need for making traditional radiographs in the operating room. Retained drill guides had not been noted on any of the official radiology reports for the three patients.
Another possible method to avoid retained angled drill guides is to fill all of the screw holes in the volar locking plate. Filling all screw holes necessitates removal of the drill guides prior to measuring and screw insertion. However, it is often unnecessary to provide additional fixation, especially in the distal row of the plate where the risk of intra-articular penetration increases with additional screws. Use of a separate angled drill guide that screws into the plate (rather than being preloaded) would prevent this complication but would increase operating-room time.
On the basis of these three cases, we recommend that when a locking-plate drill guide is inadvertently left in the patient, the guide should be removed as soon as possible so as to prevent flexor tendon rupture. Although flexor tendon rupture occurred in only one of our three patients, it is a clear risk and the potential morbidity is considerable. We also strongly recommend an additional step of palpating the plate for retained drill guides prior to closure, and/or obtaining traditional postoperative radiographs in the operating room. With these measures in place, we believe that inadvertent retention of drill guides can be entirely prevented. 