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A-1208 Conservative
Grey Giddins , UK
Thursday, June 14, 2018 · 8:31 a.m. · 17m 23s
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they think they're not a um a place and then when it's in on the to speak to
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you and i'm delighted similar you got up in the morning but probably not to hear
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me um so i'm gonna talk about the non operative management of hand from uh this is
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the vast majority of what we do and if you're not doing this you should be
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um and this is what i'm gonna talk about so quite a lot of injuries along and a major on through
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i'm gonna be quite dogmatic because fortunately the evidence is on our
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side and we can be quite dogmatic for these injuries
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so necklace bar can ah from nottingham in the
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u. k. he wrote extensively about hand faxes
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a a generation ago he's did state most hand factors could be treated non operative really which i think we know it
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no i'm not saying every fracture should be treated non operative that would be foolish
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um and there are some that we definitely have to operate on i open fractures
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some displaced intro articulate fractures to reduce ago fractures multiple injuries
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complex injuries that's not what i'm talking about today
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so this sort of thing even on i would probably operates
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well i'm talking about the fact is not needing surgery and i want to emphasise that is
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and that any fracture with the reliably good outcome with conservative treatment so this should be o.
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d. full position as usual starting position can this fractured do well if we do nothing
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and then only talking about placed on this place low energy fractures
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they're all gonna do well but we're also talking about some of the so this sort of fracture here minimally displaced
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no need to put any screws in there and the extra look lovely but it will make any difference the patient
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and what i want to emphasise is that not up to treatment is not no treatment
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sometimes it might be might be just tell patient the get go you'll be fine to
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buy any to see that some of the time it's quite careful follow up
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and in fact i think that not up to three bodies often harder than optically adoptive treatment
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but a few screws in awesome places screw send them to the third place and
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tell everyone you're mob a surgeon shows some great x. rays of the meeting
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i'm not after treatment you may have to see them weekly for several weeks you may have to make subtle adjustments to that's
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printable pasta to make sure they get a good result and you need to keep them on board with what you're doing
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so if we assume that most factors to these uh do we have to ah so which do you need surgery
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and so i'm gonna look at all these fractures and emphasise why they don't
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and i want you to be taking your thinking away from which need surgery just saying
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i'm assuming everything is and and i don't have to really justify my operations
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so i made a couple neck boxes fractious we see lots of the is as kevin is emphasise
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and this is so typical case you seeing can a presenting sort a week
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or ten days down the line are already there making a good faced
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however good your surgery you can't improve on that and if they're that good that uh early
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you're not gonna make them any better so we know is that there's no evidence the boxes
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fractures need surgery and they're being a couple of studies no x. and studies but
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straw but i'll do this you're a randomised study on west group and i looked
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at it and like most of the studies there's no difference in outcome
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but the people have said we have more complications so
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this is very difficult to justify operating on
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and what the coal benefit you might get in a slightly better drop marco you're
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gonna have a scar so there's really no reason to operate on these
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but a copy shop fractures we see quite a lot of those transverse made a coffee shop fractures
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and this can be quite easily treated here in the pasta but you could try splint
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and normally you couldn't correct the articulation to within ten degrees or so and again
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they get excellent results here they're normally pretty my bar quite quickly and that
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and again there's be work on that nicholas barton and from the same unity naughty and subsequently
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and again they showed no difference in outcomes but if you operate you have higher complication rates
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so why would you and of course then maybe the old plus and some
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international sports many nice to be back on the rugby field to go fighting again
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um a few weeks later he you do operate on but in the vast majority
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of cases you get an x. m. is out with normal to treatment
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there are exceptions and this is the sorta one where you get
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and often the fraction sometimes you can get these back
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but if you caught then i would recommend surgery just because i think
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they do do appreciably less well but that is the exception
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not the rule and that is the point about this again it's not
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every fraction need them all up to three would but most do
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and i think you need to always be thinking of subset bias i think that's what skews our conversations
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so i say transverse fractures don't need operating and some of these are yeah but the
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often the one that's really a problem and therefore i think you're talking rubbish
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and what i'm saying is not everyone there will be some sets we need in
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there that may do better and i think we've often been bear ad
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at identifying batteries so i want you to keep those in mind throughout all this conversation
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spiral made a couple fractures out good tans written quite a bit about that
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we look to the series of probably the mark and for these patients i just get them going uh early
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and they uniformly do very well the shorten slightly but a bit of
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shortening of two five millimetres makes no difference to the outcome
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and they do say well you cannot improve on that surgically so why would
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you so this sort of fracture here to because by rheumatic apple fracture
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um and that one there and we just get them going so this the patient there
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in clinic and they're about two weeks some injury and that's a range of motion
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you can't improve on that and i've done it with multiple fractures seventy three and
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i would probably do it with full um so there's no indication for surgery
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and then a potion fractures and we see quite a lot of these and we worry about evolution injuries and there's
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an awful lot to talk to in the literature about
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surgery for devotion fractures um many series written out
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so in the thing is we looked at this not a big series but a reasonable follow up
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um how what we do is we buddy strap them get them going um we body struck
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the six weeks i suspect that's probably unnecessary probably two weeks is all you need
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and again they will get an exit without so you couldn't improve
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on that with surgery so this sort of injury here
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it look tempting to fix but don't be tempted you don't need to new way to improve the outcome
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seven the thumb radio now look flatter ligament injuries and we see quite a lot of those
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in the radio flat to ligament side there is no to appoint
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erases forget the seven lesion illegal impose off but it
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should do stick back down isn't really no reason to operate on these and on the l. the collateral ligaments side
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with uh who you can occasionally with a bony devotion get a concomitant
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stand of these and it is very rare and serene in
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good when they produce that that's in long term data up to
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six years and these patients generally do very well so again
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surgery should not be your primary aim my was a shrimp
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pasta and almost all of them would do well
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and yes it will be the old one he went in maybe in time we'll find that subset and understand it better
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but you shouldn't need to operate say here on the radio platters side
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that should stable lies nicely and here that oh say does
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well even that looks like fragment that would do nicely
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and they're on the on the flat to look inside looks tempting to fix but you don't need to that we stick back down
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so just looking briefly the famine jeez which we do see see commonly and they're read three
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types in my rack this long oblique smile and transfers to the longer break fracture
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we see colour they that i really understand exactly the mechanism of how that occur as
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and this is one of many ways you can fix it but i would
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suggest to you that some necessary so this sort of fractures shorten five
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few millimetres and that doesn't seem to give functional problems in fact i saw
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this patient um about ten years off this entry for another injury
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and that's the range of motion that's what you'd expect now la gonna say to you every time with the
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five until fracture i get that sort of was out 'cause you're not gonna believe me but again
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they do say well so often that i don't think there's indication for surgery
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now i'm gonna go to joint injuries so it bony mallet injury
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this is being i mean there are so many papers on so many different ways to fix this injury and
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we worried about this and it was written up in the eighties about fixing it if there was a fracture fragment of
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more than one said that's been a strong indication of the surgery for many people so that's sort of injury here
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worry about that some boxing and so you can do there is clever operations you can even put plates and screws and the
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'cause you worry about this a caring but that fortunately is rabbit does happen and that's a typical problem to sort
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so why looked at this we put i was in the sprint and
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i look to notice some changes when you extend these fractures so
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if you when you see them if you put hyper extension stress intellectual x. ray
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you see three patents so this is the x. ray that i'm doing a hyper extension stress
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pushing it with the patients finger some yeah seeing see this one here is pivoted
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and ah come to that again and say we found a three pack and so either have it
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they plied with a tilt and if they pay that they're the high risk of sublet station and those uh probably ones you need to
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fix anything clyde they did some blocks and you could be fine
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the tilting were unclear but they probably in the gliding group
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so here this one paper it's pivoting about that the data
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structures are damaged that's got a risk of sublet station
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and it either fix it will keep replace sigh and they can move for up to three weeks
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hey at this one big fragment over fifty percent you worry about that
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but that is plainly gliding that's remaining calm grooms you put into extension they would
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do fine there's no need to fix those and then this one another
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quite as large fragment here but that's gliding more than pivoting that's a detailed and
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in my experience they do fine but on numbers of those a small uh
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so i would recommend you stress the use and you find
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that once again the vast majority don't need surgery
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so get it set subset by as we be looking at the wrong thing looking at numbers what percentage
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is a fracture fragment and actually we need to look at it more cyclists the soft tissue injury that we can't see on the x. right
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if you do that's tension stress test you could work out which small numbers need surgery
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now this also applies to the p. i. p. joins this is even more interesting in my
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um it's my mind we should be hopefully writing this up in due course next year
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the key is that the concave the base of the the middle
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phalanx is concave in concave joints are very tolerant of injury
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and we know that 'cause the distal radius is immensely tolerant of almost anything with right it
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people of worried about broadening of the base of the middle of filings on the lateral x. ray and lots of
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people said it gives you problems but there's no evidence it does and i'm pretty certain that doesn't matter
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and again the question is do they pay that or do they glide and this
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time you flex and not extend them so he uh p. long type fracture
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and you might be tempted to fix that um that this is the patient it's three weeks
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and i don't think any of us that we can do better than that i can't
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but this is a more interesting casey see this you think this fact to sublet say should
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that's a bad injury over fifty percent is well extended that's got to
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have an operation 'cause you know that patients gonna do badly
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but we got them to flex and is use easy comes into flexion
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he does pretty well so this was it about two weeks
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um i don't let me go back to that so this is around two weeks and then it as sort of a six weeks he had flexion
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in his p. i. p. joint of a hundred degrees and full movement in is t. i. p. joint
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he will have broadening the base of these possible phallic of
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these middle fans but you can't improve on that surgically
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so what i do now is like and take a lateral flexion x. ray and if they have it
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then i think they'll do badly and operate and if they glide however bad the
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x-ray looks they'll do well and i would be better than with surgery
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and then the bin it's fracture so if you read the text book most
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fraction textbooks say you should operate 'cause is an injury that does badly
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um but actually if you really look at the literature you find that that's not quite true
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so we did a systematic review and we showed that there was no difference in the outcomes in the literature
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between surgical treatment and often portly described conservative treatment some
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of which was simply get going and do nothing
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no i'm not gonna pretend that these were great studies and these were ah c. t.s underestimate 'cause they weren't
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but what he shows this is we'd gain a which ones of these
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to fix and we said we shouldn't be fixing all of them
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so we see this type of injury it yeah big fragment joints
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come out and you might think you gotta fix those
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but i what i would suggest for most of them you need to playa plus the cost and i
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apply modify bennett spots down i can explain that to anyone wants to track to me later
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i think you need to follow up caffeine for three weeks and you can mobile lies
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and the key is if you get a good reduction which you often do
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as long as that maintains they would do well then you don't need to operate and if you don't get a good reduction
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yes i would recommend surgery i think they'll do better not that we have the evidence
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for it so again i'm not saying they will need surgery but i think that
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quite a lot of them can avoid surgery with appropriate normal treatment so here nice
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reduction of that fracture that you're not gonna get back to that operation
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selling conclusions based fractures in the hand don't need surgery and your d. for position should be
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i'm gonna find a reason not to operate well now i'm gonna find a reason to operate
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this is the question you should ask yourself can you reliably improve on the natural
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history this injury you'll boxes fracture get going can you improve on that
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and for a lot of the new cards and if you don't know the natural history you should look at that 'cause
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your you i wait to your patients to know the natural history before you can advise that you can do better
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not opted treatment is not nothing about was careful follow up and some of you will have
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upright is where that can't be done your patients run reliable they're not gonna come back
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maybe they do need surgery maybe this on all our they don't even need surgery
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you should read the literature and think about subset analysis and subset
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bias to wonder whether you'll being prejudice by the wrong injury
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whenever you operate ask yourself this question
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how many people need to be a little bit better from your operation for the small percent you ruin bios a tree
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and i think you need to make a lot of people a little better to make even a few words
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and then finally where all those bad patients which reaches thirty years ago mostly non operative play
Conference Program
A-1205 Welcome and Introduction
June 14, 2018 · 8 a.m.
A-1206 Epidemiology
Kevin Chung, USA
June 14, 2018 · 8:04 a.m.
A-1206 Epidemiology Q&A
Kevin Chung, USA
June 14, 2018 · 8:16 a.m.
A-1207 Evidence
Janos Rupnik, Hungary
June 14, 2018 · 8:19 a.m.
A-1208 Conservative
Grey Giddins , UK
June 14, 2018 · 8:31 a.m.
142 views
A-1209 K-wire & cerclage
Anuj Mishra, UK
June 14, 2018 · 8:57 a.m.
119 views
A-1209 K-wire & cerclage - Q&A
Anuj Mishra, UK
June 14, 2018 · 9:08 a.m.
A-1210 Intramedullary screws
Maurizio Calcagni, Switzerland
June 14, 2018 · 9:15 a.m.
156 views
A-1210 Intramedullary screws - Q&A
Maurizio Calcagni, Switzerland
June 14, 2018 · 9:24 a.m.
A-1211 Plates & screws
Philippe Cuenod, Switzerland
June 14, 2018 · 9:29 a.m.
154 views
A-1211 Plates & screws - Q&A
Philippe Cuenod, Switzerland
June 14, 2018 · 9:42 a.m.
A-1212 External fixation
Frédéric Schuind, Belgium
June 14, 2018 · 9:45 a.m.
126 views
A-1213 Compound fractures
Thomas Giesen, Switzerland
June 14, 2018 · 9:54 a.m.
364 views
A-1213 Compound fractures - Q&A
Thomas Giesen, Switzerland
June 14, 2018 · 10:08 a.m.
238 views