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A-1296 Intra-articular fractures
Christoph Pezzei, Austria
Wednesday, June 13, 2018 · 4:33 p.m. · 11m 14s
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so very good um yeah important is here to
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remember a four indication for a surgery
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oh to restore normal anatomy in the fractures that we um that um
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always have to see um what is wrong with anatomical uh
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parameters uh we remember the rule of eleven that means
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the eleven a millimetre radio hides to twenty two railing train a a degrees of radio
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inclination and eleven to fifteen palmer inclination for chill to of the radius which is
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basic for a really repairing also the um
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proximal visitation of the fracture of the distal radius
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i'm in a order to be well it to value
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all the variance uh why don't limp action syndromes
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are important in it will ration and the just already on a joint involvement or not
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uh in the um uh fractures and especially the form uh
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which can be parallel diverting or converging must be respected
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treatment options instead of plating natural you first uh of thought is always
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do we need really to operate or can we just make a closed reduction um and the uh plaster
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um um if we do that we always check if we have a
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secondary loss of destruction we can go for secondary uh uh sir
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surgery in the second place and if we decide for surgery we
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have to remember these factors are majors associated lesions is a
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special conditions like us to project a activity or sport or
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personal request are all factors which influence this decision is
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so an atomic go uh um the reduction and stable fixation and if
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possible then early mobile edition is the aim of this operation
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um the and uh we have sit for several uh apparel meters for
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fracture instability which we all know by uh by uh oh
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for a long time um and the proximal stamp medial translation
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is something a little bit more new or concept
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with these highly unstable distill a radio on the joint where the addresses membrane
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part is getting it and unstable and then the large instabilities are created
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re operative plan identify the fractured characteristics and then execute the surgical walk through
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it does the radius fracture pattern look at what is the better how is the bone quality house d. r. u. j.
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and uh how is the amount of a continuation and then a key
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steps and provide a uh look for you avoid potential uh complications
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room setup is clear you sure that all plates are there something which can always
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happen and um the generally is very good if you have a c. r.
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which is a c. r. which is adapted for these kind of fractures and if
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they are to scope is not too far sometimes this can be helpful
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um yeah aren't running k. d. s. this is what we have
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and the the decision incisions discussion about the incisions along but
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what we all now know is that we first of all to try not to cross
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here the um the flexion increase because there's the branch of the um um
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oh it could jane is a branch of the uh median nerve which can be injured
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and we want to stay um under lateral over the f. c. r.
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and going in between the f. c. r. and the radial artery
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modified henry approach you see here the approach to um the thing is to protect
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one sensible branch of the uh median nerve on on the other side
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the the radial artery so and green so we are will to go in and go down
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um and to the to the prenatal quite writers generally we we try
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also put by protecting radial artery and the median nerve naturally
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going down the release and i what i do region
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regular they are this and uh if necessary also the first
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extensive compartment to reduce to reveal rising for says
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i can hear or release the back your uh then the prone adequate writers
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and the reconstructed afterwards if possible to protect the plate
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clear fractures side clear everything and um uh you and tried to make a reduction
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i often also user continues extension do why it's a two during preparation
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yeah uh getting restoration of the length which makes it a easier
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check to fracture uh after traction manipulation and uh then
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uh can you can use k. wires for temporary fixation
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if this is necessary at the beginning perhaps it's more often necessary then
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later can lose a little towel roles to keep it at the right position
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and then uh um the once it is rise position you fix
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it uh watching very well not to injure the radial branches
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and then there are two different techniques you can first fix the proximal part of the plate
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and then adapt to distill that uh uh this part of the radius or you fixed first
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to this to participate to the still part of a factor and reduce it over it
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but to look at the has now describe the proximal fixation uh
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plays the cortical screw in the proximal oval gliding whole first
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and then uh and insert a cortical a screw then uh the insert a cortical screwed the distal
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part after repositioning make of ross copy find out if everything is okay and then go on
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so this is the the principal uh you reduce it you put your k. wires then you put your plate then
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you do first the proximal screw and then you uh the the new put a lot screw to pull
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here the this the fragment to the plate not use a locking screw because that will not work
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in this mechanism you can also do would uh the other way around you fix
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first the distal part sorry you fix first to distill part and then
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yeah you reduce the fracture by fixing the gliding how to
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the shaft um but this is the basket effect to catch up with the dorsal fragment if there
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are also fragments so can push them against the um at the um uh uh the plate
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and um the and it's very important that here everything is placed in the rights
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of cortical a bone you see here the the direction of the different
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uh screws you are out of the continuation zone so you have good stability good length and
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we'll do that uh sometimes you need antibiotics which is a rare just planted
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um and there's a big discussion about splitting or not sprinting um
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early motion is generally required that means the aim is
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stable fixation for early motion but whirling motion is also bad if you
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have perot's commit to to a concomitant it and ligament injuries
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so don't be too aggressive with the with the early motion in
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my view uh it at the end result is the same
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so um why palmer approach why put the the plate they are because cortical bone
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here is thicker and it's easier to reduce from there there's a flat surveys
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and uh it is distance to the tendons they are far away from this
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gliding stone so you are safe when you put a plate here
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um the and uh don't put it to distill or too far away if not you're getting
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problems with your gliding tenants this is the right way to have to put it
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you see here these are the sounds not are important concept is that
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concept of the watershed line uh something which was said already before
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um depends on your fracture pattern if you need a plate which goes more to the
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alma powell palmer surveys or to the radar palmer surface of the just the radius
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and um this is this watershed line which is at the distal insertion of the pro later what right is
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is is the more distal part where you can go with the plate and some of these places plates
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are able to be adapted on the most distal part on this watershed line to get
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these uh of it to be able to fix this very very distal fractures
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and burn the other hand permit not to have and a conflict with the flex or tendons
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so um different plays are proposed as you have seen already these uh
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a simple more simple played from a simple fractures and more
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uh i'm i'm that sophisticated played for more sophisticated fractures
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these are these watershed line uh uh plates
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in this case which go where image distill also to the distal ready on the joint
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and to the to the owner a column of the of the parser phase
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well the classical one goes more to the radio column where do the radials by light
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and you see here the oath independence to what is your fracture pattern and your need you
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adapt to write material and you can get a very very stable and good fixation
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um some uh the um sup undergo support is very important if you need a more stability you
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fix also the more proximal row of the distal screws um different by amateurs are propose
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um and uh naturally the bank fixed angle at a fixed angle concept
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has renewed our uh and and helped a lot to the stability
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to these fractures we do not need 'em screws which go no no
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right to the doors apart and they really depend on this concept
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off a a fixed angle screws that means the screw had is fixed into the plate
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um you have variable angles and fixed angles that means they can have
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a little mobility or not depending on the day wise and on the technique um and
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and the need for your fracture and figs angling multi uh angle a directional screws
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uh come in this case with the unique played for us in the extra
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articulate fracture this is the the the comfort and uh um uh classification
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so um this is just one example very fast to go through with this uh
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and henry approach go down to the to the director ready
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alice you does insert the regular the others uh really
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you uh um reduce the fracture um in a clean the fracture reduce the fracture you can fix it
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with the k. where temporarily if needed um and then you fix it you fix your plate
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first uh as he described uh with this technique
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with his gliding hole and there will be the cortical screw
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and these are the fixed angle screws and uh
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can fix it this is the is the example very much dislocated and here where it
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fixations stable fixation um a step by step and
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now three months later second case another one
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and you see the an atomic reduction and the the look for the beauty and the clinical
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