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A-1297 Case discussion
Hermann Krimmer, Germany
Wednesday, June 13, 2018 · 4:44 p.m. · 20m 50s
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you are much marks i think you know week on going sure strictly to the case discussion but before
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we start i want to ask you a my speakers is everybody off you going for it
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post operative cities can pretty operative of cause we i think there is
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consensus that we have to need to c. t. scan especially for
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in brightly coloured fractures but who is going for routinely
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for post op c. t. scan will come
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but can you you'll be doomed we don't do it routinely but if there
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is any doubt that we have not uh call rectory position or reduction
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well if there is a screw into article uh really uh we do it yeah
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sometimes from uh the normal huh x. rays very convenient
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and uh if you do the c. t.
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scan your really it's not to say fuck of
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that situation looks quite different uh then the
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a normal each really so don't do it
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too often but do it if it's necessary i would say i think
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that's a point you say don't we too often don't don't
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said you see what you're not done really perfectly yeah yeah i have now switched completely different and if we
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are dealing misinterpreted you learn fractions we're doing routinely a
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post optically scanned and sometimes it's really surprising
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beefy save set all this at anatomically reduce but absolutely it
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it's not 'cause of what do you think about
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same same as as you said we we we didn't do the c.
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t. scan post operative routinely but only in in speeches cases
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but also in a retrospective every two it is something we receive looked
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at some cases it's all that also in case it without
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post operative everything is in good shape we saw the c. t. scan it was so that there is
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uh some torn a fragment still so i think we should do it if
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possible more often than we think oh you're right i think marks
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for extra particular factor i think there is a need i things are going to okay now we are going to the case discussion
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or just want to present your this case is a fifty eight you though it may work for from c.
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neatness and actually it is yeah fracture bought it looks
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it so the particular services will fall preserve
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and as he had also is other wrist insured and e. s. summer trek just as a first
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that was down uh by external fixes that and it was so for probably reduce and
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if one looks at this fractured look quite so for white okay but
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it's it's a call for c. t. scan and then you
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really see the what's really the problem and now we have to
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think about what comes to mock and we have to think
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what's to going on for all a decision making for treatment of
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this fracture because we have this location and on our side
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and you ought to have commuted area on the other side and then
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there is a problem what kind of procedures shall we use
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we didn't mention one very popular principle which is very
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popular in us that means is spending plate
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one might this class if it would be read you would just
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maybe spending plate i have no experience we don't use it but one
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can discuss it but any basic question is do we have
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material available maybe really can stable fix it and the other question is uh
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from which side both sides and move from which side we should call
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for the major for stabilisation it means
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palm our approach primarily taught approach problematic double approach
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trade off the plate and is there any kind of meat off a bone graft
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christoph yes yeah i have a question on the left side is this fragment on the other side this
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is twisted around receipt anatomically store it it is existed the wrong is torn yeah so we have
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to reduce it and you can't do it from the doors that's that's they have to come from the bowlers
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and for stabilisation you have also go for the torso set so
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you think you have to go for a double approach
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and for stabilisation um probably from post said this fragment specific plates
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or at least 'kay virus so we have hostile uh
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nature of sucky fragments for congress a key fragment you
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said it really i think the key fragment this
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top areas no key frame i don't know yeah because it is adapted to the ball off redman
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and that's not dislocated we still luna so so it's no if you have
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that also commie notions on under very vied these double she a fracture
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but that's the most complicated type because the question is not how to reduce it
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it's also present i'll fix it uh and uh i would going
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from double aside i think it's not turn around it's only
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wrapped up i think are uh_huh do which one huge turn around
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the the whole palmer fragment we have to see more c. d.'s but we
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don't have a you don't tell they are they are that retaking is
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why do we need a a and fix up there it's down
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has a problem or he was my telling to work it was obligations okay it's
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okay and i think it's a good straight she iffy iffy comes at night
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next fix c. t. scan button go for surgery at midnight ah okay yeah
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soul by the question is from which side do you want to stop
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in from which side we want to tuesday may just stabilisation i
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was openly on how not i would going from that will aside as
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we do it in ninety five percent of all the cases
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and try to fix it try to reduce it is
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um play stop short sometimes we can do also
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not ninety degrees turned around fragments but the press to detach fragments
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we can push up um that could danielle slip and then
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put on and very bite the style plate to
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means frame late or a fruit plate
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uh and cool with the screws on the the article or surface it's like swimming ice to
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the fragments and then if it's not possible to to reduce it to to keep the carpal simple solution
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and an additional rule primary stabilisation part my family yeah marks
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i would agree go go from palmer see what that also fragment does and
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then if i needed to win case or so uh approached would
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what should line played from the power part might do with the and the the problem is it then it is still stable
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okay i think there is some consensus may have to go from both sides i think it's not i think not
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possible to reduce it if you start it from the palm aside of course you can read uses fragment
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but i think you will have a problem because to lifted up risque was it's commuted it's difficult
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tell me personally it was also difficult to go for decision but i felt
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the major problem is that's a docile aspect because i don't have solid bones and i just want to support
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it's all are so uh uh approach was primarily that awful and the board on it also plate
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this is some kind of a room plate which gives you a
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good supporters that also room ends upon my aspects it means
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this fragment which was already order was always dislocated even when we had inside ought also played
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and for that reason we went for the palm aspect and we
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used to use tiny screws it is one point one one
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point five to fix trusts upon around and was it twisted null
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and then of course post operative sees can you feel
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good but check yeah and be be checked it
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and it was not perfectly but you can
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see yeah that's the major large really that's a that's an aunt nice not visible us
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no it's a c. t. but it it anyway i saw him and he i recommend it in now hardware removed
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it we always recommend to remove daughter plates but he was but do i have no complaints just leave it
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okay in semi switch over to case number all
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we already had about chief recommends and that's a
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neat rubber fixation and our uh next case
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is dealing with a case where we have real pretty c. t. scan
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both operative a c. t. scan and we all the problems
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this was this type of rec shape looks not that
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difficult ah when you're going for c. t. scan
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use the ski frick and that means is is a new nate for set fragment
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which can be troublesome and it was fixed were is a palm up late
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and our drummer selection are very precisely c. don't cough go for
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a normal radio graphic just go for a c. t. scan
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and this is the c. t. scan and now it's anatomically reduce
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it looks all file perfect buff it's what might be wrong or is it okay
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i can believe it or can we expect anatomically yeah only one column
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and only one cullen and told and and not enough uh support on the
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ball or set the plate is positioned to to la problem proximal
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yeah what can yeah the problem is uh to distort fragment is not in one piece and you have the
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you can see it here very clearly a fracture line directly over the plate yeah yeah and uh
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as in test set yeah also that there's also the already there are
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some look station of the rest uh it's it's already probably shifting
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yes so i think it was not the right plate for the tad anaheim part was that it's
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is c. area where we shall insert always screws this study
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and it's the most stable area is sub control and stop compress it means
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who should run yeah because you in this part to add just scandalous bone cancer risk for
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secondary six seven a separate station is very high and actually this is what happened
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two months later and sense of promise action sends a case to us as a couple substation
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of course we have a c. t. scan and it looks in that way and now
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there is a question
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correctional still to me a search procedure adjusted innovation
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sometimes people is the doing what good is
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such a thing work that needs just three out how long are we from fixation
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that's the link went to meant to put two months and range of motion range
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of motion is very painful twenty extension answered if it falls this patient
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the uh oh he's actually in this case he says so the old also a very young another always lately
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so i would try to to secondary repetition put
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away the plate fixed a cop pulls
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that means a four leaf up table of fragment uh to with
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friends fixation of sit on it in the right position
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and put a plate on the little are these dull core not maybe a a kawasaki
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or if p. l. plate or something which which is very light easterly uh_huh
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yeah that's the same i yeah i would try to reconstruct it but i think it
00:12:55
only works in about twenty percent and at the next step would be hours yeah
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okay i think there's some consensus the young patient would give our
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best and go for a revision searches that what we get
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and concerning plate selection of course we cannot use a conventional plate because
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our major problem is you're on the on the side that mean we
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need at late it gives us a high amount of stability
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and maybe he also need some additional uh stabilisation and this was all we did it
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we used uh uh the s. and p. l. plate to really catch this fragment all the on our side
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and what you learned in how a cool works together with our friends from b. n. huh is because
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there is an increased risk of secondary subjects e. station even after this revision surgery
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and under these circumstances after revision of the two moms or even of the sixties
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the goal for annotation only stabilisation of the right to copy trying
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this because this increases us stability of the corpus and
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what happen of the removal of the k. whereas of course they did not
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this was a finer incisive is doing quite fine part maybe ass out some criticism
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of course now yep outline action that means probably and such a
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case one have to think about a bar graph occasionally
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and uh of course is yeah stable for hot very move it because uh this
00:14:37
the screws over if like destiny but anyway if the most important or
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thing what we have reached my eyes still set i'll
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i'll corpus is a summarise into rages i
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think because even if you if it's a little bit distraught to rate you capitulate uh
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it it gives us hope for example in this case one about talking golf secondary iffy symptomatic
00:15:02
for uh i know shorting and now we're coming to our last case it's numbers really
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um the last cases dealing what we can learn from such
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a case it means what should be our initial treatment
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same
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the most really difficult a fraction as i usually is a
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very distal fracture speech out this deletes from uh the
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uh what i should line this was the case more back acted
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and we can see here in particular step off and
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this was the c. t. scan that means the fracture line is running very fop
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our money and we also have a select that rachel style a fragment
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and this is the situation that means we have the fracture lines running through the
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whole watershed lines that means the regular garbage on when you can see you
00:16:09
yeah and it's u. t. i. next is on the letter of the u. h.
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so that means of fracture lines running smoother or a watershed line
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and then questions again approach which kind of plate
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run fragment can be also fix it is grooves at least two plates
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and shall we go for timber right you cover fixation or well actually
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try expects is only fortress copy she was the pictures again
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you want more slices to know that i don't get it is urgent need for our
00:17:00
just copy and i don't not thinking urgent need for just fifteen is good
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i think address could be is not mandatory no case says more the problem how
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to fix it quest of what would you up the of that to
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where there's a first problems the boiler room to their indeed a book plate
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or a unit for set plate and the other problem is the radio
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but it doesn't know it to you in the those up late for the reveals that it
00:17:26
maybe you you need to play it for men specific or you take
00:17:30
uh you use of frame plate in addition a little bit
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what go
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while i agree we seem okay that means you will
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have to address the regular stylish a text
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okay good great selection i completely agree that makes sense we
00:17:51
need something where you can go very far destiny
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and this was all operate selection and it's exactly a plate
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and then you see really the advantage of this plate
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it really gives you support very far distant league fans of pauses out i'm not yet to check it
00:18:11
and i think these other cases we have to go for a
00:18:14
post operative sticky scam and it's not perfect uh uh confess
00:18:21
anyway we have two screws in the raiders dilate and we have here this fixation
00:18:26
is two screws in a saloon it said it means with this plate
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even if you to this special crepe we are
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able to address the radius dilate s.
00:18:41
l. a. s. saloon it fits that it's not always possible but i think
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it makes life sometimes for us and you are easier so marks would say
00:18:52
an outdoors copy would be helpful because we have a little step off
00:18:56
yeah so the question is when do we need to not roles copy really and when it is
00:19:02
and then then it is only yeah yeah and accessory thing that if we could use
00:19:12
oh well i'm i i take it and i i
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i think i needed when my reduction is not
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really perfect the that's a real big help because uh there i
00:19:24
can see uh how we can uh the intro article really
00:19:28
stable as it uh put it in the right direction and then fix it uh um with the help of theirs
00:19:35
the first uh a thing which can really help and as we see we asked
00:19:40
for secondary c. t. scans because we are not sure about our surveys
00:19:45
they are uh are just copy can help you interpretive lee instead of
00:19:48
going into radiology department and bring you back in your information room
00:19:53
that is a helpful to hear a a fortress puppy and
00:19:57
um yeah i mean uh in these cases uh
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uh it is not a mandatory tool but uh i personally had
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also cases where it was not sure is my screws somewhere there
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or is it in or not and so that there are
00:20:14
really helpful moments where you can get from a look in south korea's him
00:20:19
ha indication nothing still has impacted fragments especially that that contract just
00:20:25
i mean you really cannot really yeah i have a direct viewing to switch on or you don't want
00:20:30
to have it because you want to fix it from farm approach senators copied uh it is helpful
00:20:36
okay now we and say and thank you very much sink you fall must because
00:20:40
i think it was a good the could talk some good discussion around
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