OT notes · Orthopaedics

ORIF of distal radius with volar locking plate

Usual anaesthesia
Brachial plexus block (supraclavicular or infraclavicular) or general anaesthesia
Position
Supine with the arm on an arm table, upper-arm tourniquet, surgeon seated
Setting
emergency

Operative note template for open reduction and volar locking plate fixation of a distal radius fracture, with a filled example for a dorsally displaced extra-articular fracture in a middle-aged woman.

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Blank template

Follow this order in the case sheet. Tick the options that apply and fill the blanks.

Patient and case

  1. Name / Age / Sex
  2. UHID / IP no. / Ward-Bed
  3. Date of surgery / OT no.
  4. CaseElectiveEmergency (non-elective)if emergency, state urgency and reason
  5. Timesin OT ___ anaesthesia start ___ incision ___ closure ___ out of OT ___

Team

  1. Operating surgeonname, designation
  2. Assistant(s)
  3. Supervising consultantpresent in OT / available / not applicable
  4. Steps done by the residentwhole procedure / named steps, under whose supervision
  5. Anaesthetist
  6. Scrub nurse / circulating nurse

Diagnosis and procedure

  1. Pre-operative diagnosis
  2. Post-operative diagnosis
  3. Procedure planned
  4. Procedure performedif different from plan, state why
  5. Extra procedure done and reason'none' if none. Only to save life or health if not consented

Consent and safety checks

  1. Informed consentGeneralProcedure-specificHigh-riskAnaesthesiain a language the patient understands: language ___ witness ___
  2. Site / side markedYesNot applicable
  3. WHO Surgical Safety ChecklistSign inTime outSign out
  4. Antibiotic prophylaxisdrug, dose, route, time given before incision
  5. VTE prophylaxisMechanicalPharmacologicalNot indicated

Risks to explain in the consent for this operation

  • flexor or extensor tendon irritation or rupture (FPL, EPL)
  • median nerve or palmar cutaneous branch injury, carpal tunnel symptoms
  • screw entering the wrist joint
  • loss of reduction or malunion
  • wound infection
  • wrist stiffness and complex regional pain syndrome
  • prominent implant, later removal
  • need for extra fixation (K-wires, external fixator, bone graft)

Pre-operative details for this operation

  1. Side, hand dominance and fracture typeextra-articular / partial articular / complete articular; dorsal or volar displacement; ulnar styloid fracture; open or closed
  2. X-ray parameters before surgeryradial inclination, radial height / ulnar variance, palmar tilt, articular step-off; CT if articular pattern unclear
  3. Pre-op distal neurovascular statusradial pulse, capillary refill, median nerve sensation (index pulp) and thenar power, ulnar and radial nerve
  4. Anticoagulants / antiplateletsNoneStopped (drug, date)Continued on physician advice
  5. Plate system and back-up checkedvolar locking plate set complete; K-wires, external fixator and bone graft substitute available

Anaesthesia and position

  1. AnaesthesiaSupraclavicular blockInfraclavicular blockGeneral
  2. PositionSupine, arm on hand table
  3. Tourniquetupper arm; pressure mmHg; inflation and release times
  4. TractionBy assistantFinger traps with weights
  5. C-arm / mini C-armdirection of entry

Operative findings

  1. Fracture pattern seencomminution dorsal / volar, articular fragments, impaction
  2. Median nerve and tendonsmedian nerve seen and intact; FPL intact
  3. Reduction achieved on C-armradial inclination, radial height, palmar tilt, articular step under 2 mm
  4. DRUJ stability after fixationStableUnstable: ulnar styloid fixed / TFCC repaired / above-elbow splint

Procedure (steps)

  1. Exsanguination and tourniquetmethod, pressure, time
  2. IncisionLongitudinal over FCR (modified Henry)Between radial artery and FCRlength in cm; zigzag if crossing wrist crease
  3. Deep dissectionFCR sheath opened, FCR retracted ulnarly, FPL swept ulnarly, radial artery protected, palmar cutaneous branch protected
  4. Pronator quadratusL-shaped / radial incision, elevated as ulnar-based flapTorn by injury
  5. BrachioradialisNot releasedReleasedZ-lengthened
  6. Reductiontraction, Freer elevator through fracture, joint surface reduced first, provisional K-wires (number, size)
  7. Plate positionat or proximal to the watershed line, centred on shaft on true AP; first screw in oblong hole
  8. Distal locking screws / pegsnumber, lengths; drilled without breaching dorsal cortex; ulnar-sided first
  9. Proximal shaft screwsnumber, type (cortical / locking)
  10. C-arm checktrue AP, 20 degree tilted lateral, dorsal horizon view for screw tips; number of images saved
  11. Extra fixationNoneK-wires left inBone graft / substituteExternal fixatorUlnar styloid K-wire
  12. DRUJ stress test
  13. Tourniquet released, haemostasistime

Closure, drains and dressing

  1. Pronator quadratusRepaired with 3-0 absorbableNot repairable, left
  2. Subcutaneous tissue4-0 absorbable
  3. SkinInterrupted nylon 4-0Subcuticular
  4. DrainNoneSuction drain (reason)
  5. Local anaesthetic infiltrationdrug, volume
  6. SplintBelow-elbow volar slab, wrist neutral, MCP joints freeSugar-tong / above-elbow slab in supination
  7. Distal neurovascular status at end

Specimens and implants

  1. Volar locking plateleft / right, width (narrow / standard), shaft holes, material, make, lot/batch number, sticker pasted
  2. Screwsnumber and length of distal locking screws / pegs; number and length of shaft screws; lot/batch
  3. K-wires left innumber, size, buried or outside skin
  4. C-arm images saved

End of procedure

  1. Estimated blood lossml
  2. IV fluids and blood / products givenfluids (ml); blood: type, units, bag nos.
  3. Swab, needle and instrument countCorrectIncorrect: action taken
  4. Intra-operative complications / difficultieswhat happened and what was done; 'none' if none
  5. Implant stickersNo implantAffixed in case sheet, OT register and for discharge summary
  6. Condition at end of surgery / shifted toPACUWardICU/HDU

Post-operative orders

  1. Elevationhand above heart level for at least 3 days
  2. Finger movementactive finger movement every hour from day 1
  3. Neurovascular checkscapillary refill, median nerve sensation, pain; loosen dressing if tight
  4. Analgesiadrug, dose, frequency
  5. Vitamin C500 mg daily for 6 weeks if unit follows it (to lower CRPS risk)
  6. Check X-rayPA and lateral wrist
  7. Splint and wound reviewat 1 week; wrist exercises start at about 1 week when fixation is stable; sutures out at about 2 weeks
  8. Osteoporosis evaluationfor older patients with low-energy injury

Signature

  1. Name and designation of person writing note
  2. Medical Council registration no.
  3. Signature / date / time of writingwrite before the patient leaves recovery

Worked example

Fictional case: Mrs. P.D., 54 years, right-hand dominant, slipped at home and fell on the outstretched right hand. Closed dorsally displaced extra-articular fracture of the right distal radius with 25 degrees dorsal tilt and 5 mm shortening after attempted closed reduction.

Case details

Date: 09/06/2026. Emergency list. OT 1.

In OT 14:10. Block given 14:15. Tourniquet inflated 14:42. Incision 14:44. Tourniquet released 15:38. Closure completed 15:55.

Surgeon: Dr A. (2nd-year resident, Orthopaedics). Assistant: Dr B. Consultant: Dr C., present in OT.

Anaesthetist: Dr D. Scrub nurse: Sr E.

Indication and pre-op

Closed extra-articular distal radius fracture, right, dorsally displaced, redisplaced in plaster: dorsal tilt 25 degrees, radial shortening 5 mm. Ulnar styloid tip fracture.

Pre-op: radial pulse palpable, capillary refill under 2 s. Median nerve sensation normal in index pulp, thenar power normal. Ulnar and radial nerve normal.

No anticoagulants. Consent taken in Hindi. Site marked. WHO checklist done.

Inj cefazolin 2 g IV at 14:25, before tourniquet inflation.

Anaesthesia and position

Right supraclavicular brachial plexus block.

Supine, right arm on hand table. Pneumatic tourniquet on right upper arm. Mini C-arm from the end of the table.

Parts painted with povidone-iodine and draped. Limb elevated for exsanguination. Tourniquet inflated to 250 mmHg at 14:42.

Procedure

7 cm longitudinal incision along the radial border of FCR, not crossing the wrist crease.

FCR sheath opened, FCR and FPL swept ulnarly with the median nerve. Radial artery protected on the radial side. Palmar cutaneous branch not seen in the field.

Pronator quadratus incised along its radial border and distal edge, elevated as an ulnar-based flap.

Fracture cleared of haematoma. Freer elevator placed across the fracture to disimpact. Traction by assistant. Dorsal tilt and length restored. Held with one 1.6 mm K-wire through the radial styloid.

Right volar distal radius locking plate, 3 shaft holes, titanium, placed proximal to the watershed line. First 3.5 mm cortical screw in the oblong hole. Plate centred on true AP view.

Distal row drilled with 2.0 mm drill without breaching the dorsal cortex. 4 distal locking screws placed, ulnar side first, each 2 mm shorter than measured (18, 20, 20, 16 mm).

2 further 3.5 mm cortical screws in the shaft (14 and 14 mm). Styloid K-wire removed.

C-arm: true AP, lateral with forearm tilted 20 degrees, and dorsal horizon view. Palmar tilt 8 degrees volar, radial inclination 21 degrees, ulnar variance neutral. No screw in the joint, no dorsal screw tip. 5 images saved.

DRUJ stable in neutral, pronation and supination. Ulnar styloid tip not fixed.

Tourniquet released at 15:38 (total 56 minutes). Haemostasis secured.

Closure

Pronator quadratus repaired with 3-0 polyglactin 910 (Vicryl) mattress sutures.

Subcutaneous tissue closed with 4-0 Vicryl. Skin with interrupted nylon (Ethilon) 4-0. No drain.

Gauze and cotton padding. Below-elbow volar slab with wrist in neutral, MCP joints free.

At end: radial pulse palpable, fingers pink, capillary refill under 2 s. Median nerve not testable because of block; to be checked when block wears off.

Specimens and implants

No specimen.

Implant: right volar distal radius locking plate, 3-hole shaft, titanium. 4 distal locking screws (16 to 20 mm), 3 shaft cortical screws 3.5 mm, 14 mm each (including the oblong-hole screw). Make and lot/batch no. as on sticker; stickers pasted in case sheet and implant register.

C-arm: 5 images saved.

End of procedure

Estimated blood loss 50 ml. Mop, needle and instrument count correct. No intra-operative complications.

Shifted to recovery, stable. Pulse 80/min, BP 130/80 mmHg.

Post-op orders

Hand elevated above heart level. Active finger movement every hour when block wears off.

Check capillary refill and median nerve sensation when block wears off; inform resident if numbness or severe pain.

Analgesia as per anaesthesia chart. Tab vitamin C 500 mg once daily for 6 weeks.

Check X-ray right wrist PA and lateral. Review at 1 week for wound and splint. Bone health evaluation at follow-up.

Signature

Dr A., JR-2, Orthopaedics. Reg. no. ________. 09/06/2026, 16:10.

Must document for this operation

  • Median nerve status before and after surgery. Median nerve symptoms are common after distal radius fractures, and only a written pre-op finding shows whether they were caused by the operation.
  • Plate position relative to the watershed line. A plate placed distal to the watershed line is linked to flexor tendon rupture; the note shows the risk was checked.
  • C-arm views used to confirm that no screw is in the joint or through the dorsal cortex, and images saved. Extensor pollicis longus (EPL) rupture from a long screw is a common complaint; saved images show what was seen at surgery.
  • Implant: plate side and size, number and length of screws, make, lot/batch number, sticker. Needed for implant recall, removal and the implant register.
  • Distal radioulnar joint (DRUJ) stability and what was done for the ulnar styloid. Decides the type of splint and explains later ulnar-sided wrist pain.
  • Tourniquet pressure and time. Required when a nerve problem or skin injury under the cuff is reviewed.

Common mistakes in these notes

  • Writing 'volar plating done' with no screw count or lengths.
  • No record of median nerve status before the block.
  • Not stating which C-arm views were taken to check screw length.
  • Leaving out the reduction obtained (tilt, inclination, height).
  • No splint type or wrist position written.

Indian practice and paperwork

  • Record the batch and serial number of the plate and screws in the case sheet; NABH also asks for it in the implant logbook and the discharge summary. (NABH Accreditation Standards for Hospitals, 5th ed. (2020), MOM.10(d))

Sources

  • Campbell's Core Orthopaedic Procedures. Elsevier; 2024, Technique 39, Volar plate fixation of fractures of the distal radius (Cosgrove CT), pp. 180-183.
  • Operative Techniques in Orthopaedic Trauma Surgery. 2nd ed. Wolters Kluwer, Ch 6, Volar plating of distal radius fractures (Fernandez JJ, Streubel PN), pp. e-book markers P.54-P.65.
  • Campbell's Operative Orthopaedics. 15th ed. Elsevier, Ch 62, Fractures of the distal radius, volar plate fixation; Ch 2, Tourniquets, pp. 2829-2833; 137-138.
  • Bratzler DW, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013;70(3):195-283. Table 1: cefazolin 2 g IV (3 g if 120 kg or more) within 60 min before incision; cefazolin recommended for implantation of internal fixation devices. academic.oup.com/ajhp/article/70/3/195/5112717
  • Operative Techniques in Orthopaedic Trauma Surgery 2e, Ch 6, postoperative care (pdf p134): vitamin C 500-1500 mg per day for 6 weeks to reduce complex regional pain syndrome; elevation for at least 3 days; wrist motion from 1 week.
  • Campbell's Operative Orthopaedics 15e, Ch 2, Tourniquets, pp. 137-138: tourniquet time 2 hours or less in healthy adults under 50; 135-255 mmHg satisfactory for the upper limb.

Educational template for residents. Adapt it to your institution's case-sheet format and your consultant's instructions. Patient details in the example are fictional.

Videos of this operation

Teaching videos and pages for this operation, listed under the curriculum item that asks for it.

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