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A-1170 PIP problems after trauma and surgery, pearls and tricks for success
Randy Bindra, Australia
Friday, June 15, 2018 · 10:42 a.m. · 09m 35s
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00:00:02
the other challenges these guys often present like right we've all seen these rugby players they come back a month later
00:00:07
set up my fingers jammed it never really started move so maybe something's wrong maybe and it again actually
00:00:13
and as we know sometimes it we think about your can be worse
00:00:16
than the injury when you do this big surgery shotgun approach and
00:00:19
i got a swollen finger but just one band again so it those are the kind of factors you gotta take into mine
00:00:25
but the other thing is a lot depends on the patient you're dealing with right you don't wanna do big precision a patient you think
00:00:31
may not be able to cooperate with the complicated a rehab protocol plus sometimes a finger is very swollen you
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gotta spend sometimes and when the the swelling down before you can even do any kind of surgical fixation
00:00:44
when you're planning the surgery or whatever people you wanna do you looking at these pieces and saying can i fix this can i make this
00:00:50
into a fixable fragment or should i use some kind of method where i'll be using the given to texas or other kind of technique
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and a lot depends on what works best in your hands you certainly don't want taken too much too early and as you get experience
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you can take a more complicated procedures as we all know and so blithely if you have a p. i. p. sublet station
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this to kind of main ways you can split the creeping into an one way would be
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getting some kind of a closed adoption and stable rising it with the perky tennis technique
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and the other one would be where you do open adoption and usually for
00:01:22
the p. happy joints were often using a boiler approach or lack approach
00:01:27
no the comics technique i like and i think this simple technique is an extension blocking pin
00:01:32
we simply insert a wire through the p. l. p. joint into the proximal
00:01:36
phalanx so the finger as a little bit a range of motion
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the question here is really the wire too long number one you'll get a soviet flexion contract yeah
00:01:44
number two you'll get infection because what happens is as a moving this wire that's penetrating the p. i. b. joint
00:01:50
you end up this in oval face chiller get septic arthritis or can be pretty hard to manage
00:01:54
so you don't wanna send this patient away you wanna watch them closely have a therapist we can see them on a weekly basis
00:02:00
and your is the best result i have that in my twenty five years of records which of i'm showing it
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and you can see you can get pretty good results with this kind of an injury and sometimes
00:02:09
you don't wanna miss that the i. p. injury that occurs concurrently with the p. l. p. injury and this is
00:02:15
a good is your malpractice in chicago way these girls play softball there's something soft about it and
00:02:19
its allies a sixteen inch ball and so they will get bad uh p. l. p. injuries
00:02:24
uh and the l. p. g.'s as you can see here and in this case we use kind of a barker spinning for both the injuries
00:02:32
now the external fixation technique that i like this one doesn't involve
00:02:35
rubber bands this'll wanted grey kittens describing this is is
00:02:38
slides because like i really have a hard time but in the wise to show them what on the photograph
00:02:43
but he's done really well is written this up and the european journal and surgery
00:02:48
and this way is a great way to get these p. long fractures largely uh i would read these
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this is showing a fracture sublet station but i use this technique when there's also fracture as well as uh
00:02:59
palmer fracture and in those cases you can't do any kind of open adoption of for those injuries
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so advantages of using actual fixate or is it there's no learning curve it's easy
00:03:10
you just have to remember which wire goes where and uh and once you once you've got it
00:03:15
and occupation is cooperative you get a pretty good range of motion from the bad injury
00:03:20
now occasionally you'll need to don't know production and typically these other larger fragments
00:03:26
and then they come late all close deduction just doesn't work like demented taxes does not work
00:03:31
uh and i like c. t. scans for two reasons number one i
00:03:35
wanna be absolutely certain that the ball so cortex is intact
00:03:39
because i'm gonna rely on that also cortex against which i'm gonna buy christie's palmer fragments
00:03:44
number two when they had this he sent trick uh depression so you can see one canal is depressed more than the other
00:03:51
what happens with this is when they start to bend the going to auditory a deformity inflection so they're very hard to
00:03:57
fix so i find these a much better offering an open adoption so the technical like is a blunder incision
00:04:04
and once you raise the skin flaps so i don't do shotgun for everybody so this got
00:04:09
blown incision and then we open the flux issue between eight to an a four
00:04:13
it's easier if you split the f. t. s. so you can detract f. t. p. to one
00:04:18
side with one slip of f. b. s. n. one f. b. asleep to the other side
00:04:23
the next step then after i excise adding colour to give me good access is to
00:04:27
cut the junction between the accessory collateral in the boiler plate on either side
00:04:31
and i leave those little comedy bits attached to the boilerplate soon not be best writing them
00:04:37
so you gently peel them away you've got this whole fragment now you take a free at i. sector
00:04:42
and you put the depressed fragments back down of the proximal phalanx put double up laid back
00:04:48
put a couple wise checked they've got things a line and then you can
00:04:51
use any kind of way a plate uh to fix the fragments
00:04:55
the flick so she does input over the implant and uh the flex attendance
00:04:59
so that your plate is nice the cover and it can isn't get irritated by the plate
00:05:04
the fixation is generally stable so you have to have an intact also cortex
00:05:09
and you can let these patients started mobile eyes simply preventing hyper extension
00:05:13
and they generally do really well they do always end up with this like direction
00:05:17
contractual but overall in the right a patient you can get good outcomes
00:05:22
now if somebody comes late as in this case all the centre fragments are now
00:05:26
a vascular that collapses all cotton stepped on them and in these cases
00:05:30
uh obviously the jaime handmade has become popular and if you haven't tried that
00:05:34
technique i think it's worthwhile crack to sing it on the cadaver
00:05:37
and then once you once you figure out how it works it's not technically very hard
00:05:42
and this is the v. sign where in properly or in the clinic you can give them a digital block and have affliction actually
00:05:49
and realise that they're not actually bending but the r. m. engine open which is why these patients have been full flexion
00:05:58
okay so here after they approach i showed you earlier now i'm releasing the collateral distillate
00:06:04
so now we're doing the full shotgun approach sometimes it also capsule is tight and you can
00:06:09
put your knife be needs that also capture the middle phalanx and realise that as well
00:06:15
you can make sure that the fact that you've got up exciting the only fragments
00:06:20
oh and take the dorsal a lit up the hem might this is funny this is
00:06:24
the fact that we used to fix that i'm attracted dislocations now i ignore those
00:06:27
pieces i simply been to see him to join back in a factor dislocation clearly
00:06:31
this this piece is not critical possibility so we take that also peace out
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there's a bit of carpentry involved the tape here is keep the keep the hammock these large if you take a
00:06:42
small piece you'll end up with the peace dying off and
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not getting good fixation acolytes peace maker defect larger
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so don't make it graph small that'll happen is you'll drop it on the floor right
00:06:55
so keep the draft large keep cutting out your defect make it effect large enough
00:06:59
so the graphics in it and then you get a little tilt on it and then you can fix it with two or three screws again
00:07:05
don't available plate as mike said only occasionally i don't get my craft upright and the hyper extending in which case
00:07:12
i'd put a stitch of the boilerplate but generally of a lot and then you let them start moving
00:07:17
lack will uh is another good approach this is more versatile than the bowler and i'll show you a situation here
00:07:24
where is the yeah and uh uh this is an american football player and he's dislocated his finger and then you wonder why that pieces
00:07:31
come out from right exact kind of football so lack of dislocation east on the collector on the radio side of the ring finger
00:07:38
but you got this piece possibly that doesn't make sense because the central
00:07:41
slip is not supposed to pull off in it also dislocation
00:07:45
turns out this is the article cartilage of the middle frame of the middle phalanx base right if you look at it closely
00:07:51
so we did a lateral approach and because that collector limit is already of whilst it
00:07:56
opens like a book on its side right and then you put that piece back
00:08:02
all of it some k. wise but largely with the small articulate fragments if you simply reduce the joint
00:08:08
the joint pressure will hold a piece back so we reduced jointly by the collateral
00:08:11
ligament and allowed him to model lies but we had to keep him
00:08:15
in a short talk range of motion for about three weeks to those wise could come up
00:08:20
so when should we use open reduction generally when everything else fails i i i don't like trance
00:08:26
articulate fixation i think it's important to get these people moving at least was small range
00:08:31
but as you saw these are technically challenging operations and you what you want to have the
00:08:35
right equipment little screws and plates uh and a good good rehab team after that
00:08:40
now if you look at all these p. i. b. factor dislocations which technique
00:08:43
is best we don't really know because nobody is compared one with another
00:08:49
all i can say is all production as a higher complication rate this takes a
00:08:52
higher so make sure you take it on only when everything else has failed
00:08:56
probably a scalable fraction getting like a mentor texas is probably the easiest simplest and safest
00:09:03
the key is though that if they do come like the prognosis is port side to get good
00:09:08
results from that so to summarise uh getting the p. i. b. join produced is the key
00:09:14
absolute conduit is not a mouse as long as you get the don't reduce
00:09:16
and it's not enjoying choose the simplest method extension blocking pin ligament
00:09:21
or texas try to move them early even if it is a short our little bit of movement is better than keeping them still
00:09:27
and set your expectations realistic from the start
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