Post-Operative Management of Internal Fixation and Indications for Removal of the Hardware in Adults
General remarks
Instructions for post-operative management after internal fixation should always be included in the surgical records or discharge summary and referral feedback.
Even after ossification, prolonged symptoms may occur in the fracture area, the cause often being something other than the hardware. In most cases, the symptoms are due to iatrogenic tissue damage from the surgical operation or to posttraumatic osteoarthritis, for instance.
If permanent internal fixation is not associated with clear complications (such as tautness of the skin because of migration of hardware, late haematogenous infection due to infection on the implant surface, recurrent rubbing at the implant site), symptoms will often not be alleviated by removing the hardware.
Today, internal fixation materials do not cause problems at airport security.
Malleolar fracture of the ankle
Operation
Lateral malleolar fractures are usually fixed with a plate and steel screws, medial malleolar fractures with screws. Biodegradable materials have also been used.
If the syndesmosis is injured, one or more syndesmosis screws are inserted from the lateral side. The screw(s) may be of biodegradable material (even if the other screws were metal).
Casting time is often 6 weeks.
Weight bearing according to the instructions from the operating surgeon, usually with the weight of the extremity (10-20 kg) for 2 weeks, after which the sutures are removed and the cast is changed
Half weight (30-40 kg) for 1-2 weeks
Full weight bearing for the last 2 weeks
Removal of the syndesmosis screw
The screw can be removed if it causes problems. The most common problems experienced are restricted range of motion and stiffness of the ankle. However, very often the screw breaks spontaneously with no inconvenience.
The removal should take place not earlier than about 10-12 weeks after the operation. The screw can be removed also in primary care following a strictly sterile technique. It is advisable not to remove the screw before the wound is healed.
Removal of the plate
A lateral malleolar plate may cause inconvenience at a late stage. In a slim patient, the plate may be visible under the skin because there is very little subcutaneous fat in the area.
The patient may report rubbing that is worse when wearing certain types of shoes.
The plate can be removed as a day surgical procedure.
Femoral intramedullary rod
Operation
As soon as pain permits, full weight bearing is usually allowed after the operation.
Removal of the rod
The upper part of the rod may cause irritation.
The rod should be removed after 1 year at the earliest, preferably after 2 years. In patients over 30-40 years of age the rod may be left in place, sometimes even in younger patients.
There is a risk of refracture.
Strenuous exercise (excessive walking, jumping, running) should be avoided for about 1 month after removal of the rod.
It is also possible to remove only the locking screws if their heads are prominent but the rod doesn't otherwise bother the patient.
Tibial intramedullary rod
Operation
Weight bearing after surgery depends on the type of fracture.
Removal of the rod
Pain in the anterior knee commonly occurs after placing an intramedullary rod to treat a tibial shaft fracture. Removal of the rod will not necessarily alleviate the pain.
The rod should be removed after 1 year at the earliest. In patients over 30-40 years of age the rod may be left in place, sometimes even in younger patients.
There is a risk of refracture.
Strenuous exercise (excessive walking, jumping, running) should be avoided for about 1 month after removal of the rod.
It is also possible to remove only the lock screws if their heads are prominent but the rod doesn't otherwise bother the patient.
Dynamic hip screw (DHS)
In younger patients (under 50 years old) is removed about 1 year after ossification, usually about 2 years from injury.
The screw is left in place in older patients.
Ulnar and radial plates
Removed only if they cause problems to the patient. Removal, if needed, after 8-12 months.
Threat of refracture is significant. Sometimes a proximal radial plate needs to be left in place if the radial nerve passing over the plate cannot be identified or released.
AC-joint injury and lateral clavicule fracture
Operation
Due to the scanty bone material, a lateral clavicle fracture is often fixed with a "hook plate". AC-joint injury may also be treated arthroscopically by stabilizing the end of the clavicle to the coracoid process using a strong thread (TightRope® ).
A wrist-neck-sling is usually worn for 1-2 weeks. After 3 weeks, active non-weight-bearing abduction up to 90 degrees is usually allowed until 6 weeks have passed since the injury, and thereafter full mobilization.
Removal of the plate
A hook plate is routinely removed at 3-6 months. Left in place, it may dig a cavity in the acromion.
Midshaft clavicle fracture
Operation
The fracture is supported by a superior plate placed on top of the clavicle or an anterior plate placed in front of the clavicle.
A wrist-neck-sling is usually worn for 1-2 weeks. After 3 weeks, active non-weight-bearing abduction up to 90 degrees is usually allowed until 6 weeks have passed since the injury, and thereafter full mobilization.
Removal of the plate
At a later stage, patients may experience rubbing in the clavicular region when carrying a backpack, for instance.
Removal of the plate is associated with an increased risk of refracture.
Olecranon fracture
Operation
The fracture is traditionally supported by a tension band.
Use of anatomic plates has increased lately.
After surgery, a long arm cast with flexed elbow is usually placed on the limb; active movement exercises should be started after removing the cast.
Removal of the hardware
Pins used for tension band wiring fairly often start to migrate as the fracture heals. They are usually palpable underneath the skin, and the skin starts to get taut. The operating unit should be consulted about the removal of the pins in good time.
Plates may cause rubbing and pressure symptoms if patients need to lean on their elbows.
Kirschner pins in fingers
Pins inserted because of injury can be removed after 3-4 weeks. Pins used for arthrodesis can be removed after 3 months, if they are palpable.