span scan plan2 - aado · span preliminary reduction of gross mal-alignment immobilisation of the...
TRANSCRIPT
1
1
Management of Management of PeriPeri--ArticularArticular FracturesFractures
Span Span -- Scan Scan -- PlanPlan
WY ShenWY Shen
2
2 © WY Shen
SpanSpan
Preliminary reduction of gross malPreliminary reduction of gross mal--alignmentalignmentImmobilisation of the involved jointImmobilisation of the involved joint
Synthetic cast, applied and then Synthetic cast, applied and then bivalvedbivalvedSpanningSpanning External External FixatorFixator
Spanning could be achieved with cast or external fixator.
3
3 © WY Shen
Purpose of Purpose of ““SpanningSpanning””
Rest and observe the soft tissuesRest and observe the soft tissuesCorrect the gross malCorrect the gross mal--alignment foralignment for
better Xbetter X--raysraysCT ScanCT Scan
Buy time for better planning Buy time for better planning and soft tissue management!and soft tissue management!
4
4 © WY Shen
Spanning External FixationSpanning External Fixation
Provides stability to restore the limb closer to its normal anatomy and allows faster resolution of soft-tissue swelling than do splints or other forms of temporary immobilization.
Provides access for wound care and compartment monitoring and offer sufficient stability for early patient mobilization.
5
5 © WY Shen
Spanning External FixationSpanning External Fixation
Just restore gross Rotation, Axis and Length (in Just restore gross Rotation, Axis and Length (in that order) that order) acrossacross the jointthe jointNo need to be sophisticated or perfectNo need to be sophisticated or perfectPins and clamps should be placed reasonably far Pins and clamps should be placed reasonably far from the fracture site from the fracture site ––
Will not interfere with CT scanningWill not interfere with CT scanningKeeps virgin field for option of platingKeeps virgin field for option of plating
A A Strategic StepStrategic Step in Highin High--energy energy PeriPeri--ArticularArticular Fractures, and Open FracturesFractures, and Open Fractures
6
6 © WY ShenAO Manual, Internal Fixators, 2006
Poor Placement of Clamps will Poor Placement of Clamps will obstruct plain xobstruct plain x--ray and CT!ray and CT!
Thus, remember not to position any metal near the fracture site. Otherwise, they will obstruct the view on plain x-rays, or cause severe interference in CT.
7
7 © WY Shen
Spanning Ex FixSpanning Ex Fix
Berkson et al: JAAOS, 2006
Since the spanning external fixator is a temporary device, it does not matter if it was inserted through the quadriceps. If the fixator is expected to last for more than 5 to 7 days, the transfixion pins should then be removed and inserted from the postero-lateral aspect into the femur, so as not to transfix any major muscle group. The initial fixation need only be very simple, safe and expedient. Stay well away from the fracture site.
8
8 © WY Shen
ScanScan
CT tells a lot more than plain XCT tells a lot more than plain X--rayray
CT gives a far better 3CT gives a far better 3--D picture even D picture even without 3without 3--D reconstruction viewsD reconstruction views
CT allows accurate measurements if you CT allows accurate measurements if you can view it oncan view it on--lineline
9
9 © WY Shen
ScanScan
Taking CT scans in addition to plain radiographs affected fracture classification, and thus the surgical plan, in >25% of cases
Chan et al: J Orthop Trauma 1997.
Degree of articular depression often is under-appreciated on plain radiographs
Liow et al: Orthopedics 1999.
10
10 © WY Shen
PlanPlan
A plan is a proposed or intended A plan is a proposed or intended method of of getting from one set of getting from one set of circumstances to to another. They are often used to move from the another. They are often used to move from the present situation, towards the achievement of present situation, towards the achievement of one or more one or more objectives or goals.or goals. ((WikipediaWikipedia))
Anticipate Anticipate Reflect Reflect
difficulties
on your own experience
Anticipated difficulties and solutions are important ingredients of a plan. The capability of the whole team together is more important than the capability of the individual surgeon.
11
11 © WY Shen
CircumstancesCircumstances
An Analysis of An Analysis of Fracture type and patternFracture type and patternEnergy level and soft tissue conditionEnergy level and soft tissue conditionFunctional requirementFunctional requirementOverall background Overall background –– multiple injuries, age, multiple injuries, age, jobjob……....What could be achieved, and what couldnWhat could be achieved, and what couldn’’t be t be attainedattained
“Circumstances” as in the definition of “Plan”, include…….
12
12 © WY Shen
ObjectivesObjectives
Somewhere betweenSomewhere betweenFull reconstruction Full reconstruction –– anatomical reduction and anatomical reduction and alignment, congruent alignment, congruent articulararticular surfacesurface
Reconstruct alignment, bony framework and Reconstruct alignment, bony framework and ligamentousligamentous stability for later joint replacementstability for later joint replacement
Mangled? Forget about it!Mangled? Forget about it!
Objectives should be set realistically.
13
13 © WY Shen
PlanningPlanningNot just about how you put the fragments back Not just about how you put the fragments back togethertogetherChoice of implantChoice of implantDirection of screws and wires Direction of screws and wires ……....Timing and staging of operationTiming and staging of operationDetailed steps and required instrumentsDetailed steps and required instrumentsMaking Plan A and B andMaking Plan A and B and…….. contingency plans.. contingency plansAn opportunity to discuss with the patient when An opportunity to discuss with the patient when mentally and emotionally more settled.mentally and emotionally more settled.
14
14 © WY Shen
Plan Plan –– Reduction StrategyReduction Strategy
Indirect reduction techniquesIndirect reduction techniquesSoft tissue preservationSoft tissue preservationRestoring both joint congruity and the mechanical axis
15
15 © WY Shen
Plan Plan –– Choice of ImplantsChoice of ImplantsInternal fixation Internal fixation –– traditional buttress / LISS / traditional buttress / LISS / MIPO / other locking plates? Approach?MIPO / other locking plates? Approach?Additional Screws Additional Screws –– CannulatedCannulated? Size? ? Size? Direction? Sequence?Direction? Sequence?External Fixation External Fixation ––
Traditional / Hybrid / RingTraditional / Hybrid / RingCross or not crossing the jointCross or not crossing the jointAdditional minimal internal fixation?Additional minimal internal fixation?
Bone graft? / Bone Substitute?Bone graft? / Bone Substitute?Fluoroscopy alone? / Arthroscopy as well?Fluoroscopy alone? / Arthroscopy as well?
16
16 © WY Shen
F/80, Open Injury IIIAF/80, Open Injury IIIA
17
17 © WY Shen
Spanned & Spanned & DebridedDebrided
The open wound was debrided and lavaged. The fracture was reduced and held immobilised with a spanning external fixator.
18
18 © WY Shen
Fixed without Scanning, Wd Closed, D3Fixed without Scanning, Wd Closed, D3
However, the surgeon was too eager to operate. He did so on Day 3 without any CT.
19
19 © WY Shen
PostPost--Op. : Closed wd broke down on D8!Op. : Closed wd broke down on D8!
Inadequate reduction/fixation at the lateral aspect of the tibial pilon. Worse still, the closed wound broke down. Lesson learned: be patient with management of the soft tissues, especially in old patients.
20
20 © WY Shen
M/32, Closed fractureM/32, Closed fracture
21
21 © WY Shen
Scanned after Spanning with SlabScanned after Spanning with Slab
The yellow line on the left indicates the level of the axial cut displayed on the right.
22
22 © WY Shen
23
23 © WY Shen
24
24 © WY Shen
25
25 © WY Shen
26
26 © WY Shen
CT showed the # not seen on XCT showed the # not seen on X--RayRay
An unexpected crack was found at the medial malleolus.
27
27 © WY Shen
PlannedPlanned
1
2
1. Fix the undisplaced #2. Percutaneous clamp + Mini-open Screw
The plan was to insert cannulated screws. First to fix the undisplaced medial fracture. Then the second one to fix the antero-lateral fracture, after reducing the “trap door” fracture through a small wound – to free and protect the anterior tendons, and to achieve reduction.
28
28 © WY Shen
29
29 © WY Shen
30
30 © WY Shen
TreatmentTreatment
PercutaneousPercutaneous cannulatedcannulated screw fixation for the screw fixation for the medial medial malleolusmalleolus..
MiniMini--open wound over the open wound over the anteroantero--lateral aspect lateral aspect and and cannulatedcannulated screw fixation of the distal tibia screw fixation of the distal tibia fragment. fragment.
31
31 © WY Shen
Fixed as PlannedFixed as Planned
32
32 © WY Shen
Fixed as PlannedFixed as Planned
33
33 © WY Shen
M/27, Closed Sprain InjuryM/27, Closed Sprain Injury
34
34 © WY Shen
Reduced and Spanned with Reduced and Spanned with DynacastDynacast SlabSlab
35
35 © WY Shen
K-wire
Scanned / PlannedScanned / Planned
36
36 © WY Shen
37
37 © WY Shen
38
38 © WY Shen
39
39 © WY Shen
40
40 © WY Shen
Screw with washer
41
41 © WY Shen
Screw with washer
42
42 © WY Shen
Fixed as PlannedFixed as Planned
43
43 © WY Shen
PostPost--Op.Op.
44
44 © WY Shen
PlanPlan
A plan is a proposed or intended A plan is a proposed or intended method of of getting from one set of getting from one set of circumstances to to another. They are often used to move from the another. They are often used to move from the present situation, towards the achievement of present situation, towards the achievement of one or more one or more objectives or goals.or goals. ((WikipediaWikipedia))
Anticipate difficultiesAnticipate difficultiesReflect on your own experienceReflect on your own experience
Remember to plan well!
45
45 © WY Shen
Excellent ReviewExcellent Review
High-Energy Tibial Plateau Fractures
Berkson & VirkusJ Am Acad Orthop Surg 2006;14: 20-31