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A-1231 Phalanx intraarticular
David Shewring, UK
Friday, June 15, 2018 · 11:47 a.m. · 11m 42s
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um we see a lot of these injuries where i am in
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cardiff which is in south wales for two main reasons
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first of all is the popularity of the sport which is rugby
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union and it's played all ages from cradle to grave
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and you can see in this picture that have a little the fingers are on the second is this place we don't get
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much snow in the u. k. and so people going practised the skiing on these dry ski slopes and they are real
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many says i can imagine eighty kilograms travelling at twenty kilograms of our concentrated through a single
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digits starting up again so that this having combating and there's gonna be no contest
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so when the so when it when assessing these injuries the strapping must be removed prior to examination on price
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rotating rate across this trade off with the tape in place is one that should never been taken
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it's important to get a true actual specifically of the injured part what actually
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happens is gonna be actually p. l. p. joint whatever's being injured
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this interview was initially mistakenly thought to be some innocuous
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injury with the slide flake off the palmer aspects
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of the middle phonics which we see often but in fact when it should actions of change
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you can see that in fact it's a much more serious injury and there's also fracture this location is one of
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the more common patterns of p. i. p. joint injury that we see they would use readily but they're unstable
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well more stable infection and they can be treated with dorsal blocks print age in compliant patients
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alternatively trans article why can be used is easy and reliable
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uh why essays into battery half weeks and then it's taken out and you can mobile noise the movers the joint
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as much just will tolerate under supervision both artists or you can use a dorsal blocking why but that
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is a little bit more unreliable and we do see some re dislocations when people use those
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condor fractures of the final jeez are relatively common and they may occurs
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the results of actually doing the digit resulting in tilting at
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the joint and assuring stress can be fairly recently published a paper
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on these of some default condor fractures over twelve year period
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the break fracture pattern on the typical condor of the of the typical condor fracture renders them inherently unstable
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mount union will result in deformity and articulating convert c. on the possibility of later structures this
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they are difficult to treat normal principally to seven stability out
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of our twelve and display structures five displaced meeting fixation
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seven remain the displaced and interesting me they were all in children and
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it may be that structure is a more stable engine in children
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due to the f. a. cup areas to which remain which they may remain intact when there and displaced
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the difference is still quite as to the structures in children to displace requiring fixation
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sixty two patients presenting with display structures were treated with prior into the
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fixation and we did this within four days presentations router nick
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so he was there for performance i mean actively on a on a tasted unit we use a lot to approach
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and here you can see the the school right okay the fibres which uh which are incised and repaired later
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you can flip the fracture i've trivially cancerous services and then you can gently clean those
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the fractures then reduce the collateral ligament itself is then elevated slightly from the console just enough to
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facilitate placement of the screw and a little indentation is made a scene here at the intended
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selective school placement so the drill bit doesn't scale leave off when you start getting
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this aids accurate placement to screw which is crucial you don't really get a second chance with
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these low profile screw had doesn't interfere with the collateral ligament excursion as the joint moved
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and then the fingers closed and a reverse uh times i never and need to use more than one screw
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uh we can mobile is them easily and that would that would know last fixation
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a combination of uh the reduction of the into situations of the
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of of relatively fresh structure and some compression expert good stability
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a one patient presented with the files k. y. fixation from
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another sensor and this was revised to like screw fixation
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occasionally as the results of delay presentation of the patients will like or for
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all from a sense of these functions percent of the several weeks
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but it is still possible to take them down even up to eight weeks after initial injury
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and although these links fixations had more residual stiffness it's still preferable to the prospect of into
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columns are still to be for he'll smile union which is a significant technical challenge
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they may results uh as a result of higher high energy axial loading
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of the fingertip for example when it's miss catching a cricket ball or baseball
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on there then likely to be comedy to them and maybe by consular
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the article service maybe buckles and the so called concerts but
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maybe compressed making a production difficult or even impossible
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and all these factors as well as of more extensive social approach contribute to the poll results even the bike on the group
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and in these cases it says well that decision is prepared and the patients will
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and so a single sub topic large screws use reach condo inserted through lots of approach
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but i have some months made fixation technically challenging the few days makes
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no difference and so they can be dealt with some activity
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next we move on to the uh pay more of constantly
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the comedy toot fractions of the base the middle frank's possibly one of the biggest challenges will
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the injuries range from these type pension jeez such as here uh to the more disastrous plan on
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tight fractures there'll represents a considerable management problem problem to pay wise and not the answer yeah
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a dynamic fixate is a very popular now are very useful option
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they do require a high degree of patient compliance and they
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may be percent with some problems such as pin site infections so they do need to be looked after very carefully
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the main problem with these injuries is the articulate income growth c. and the intolerance of the
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p. l. p. george itself due to the uh to to to injury in general
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well then maybe some re modelling and uh and some patients us any more tolerant of these injuries
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the result is often a painful joint with stiffness swelling in craps
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and so the ideal situation is to restore the that's me as accurately as possible with correction of the
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uh in congress of the joints and a fixation stable enough to for me didn't reply station
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i went if i do consider fixation which is certainly not in every case it's rare uh
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you have to make it clear to the patient but it is a terrible injury
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and if if if we leave it like this then there's a very high charts up or results if we intervene we
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may still get results but we might get a good results and if you are considering fixing these injuries then
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to understand them it's it's useful to could consider the creative mechanics
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the mechanisms is usually an x. you forced to the to the thing yeah
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with the digits in extension the forces transmitted through the portal finds into the
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base the middle francs and there's pounds when you can be created
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if no central element forms than the t. shaped structure rises result resulting in appealing fracture
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if essential element does full not the type punch and fractures created
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and the base the middle findings can be considered in terms of
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three columns central column which the type punch to prefer columns
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for the for the central type and come to be created that one of the two prefer columns they have to move apart
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one of the may remain intact but at least one of them has to be fracture software up to like the type punch adamant to occur
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in this illustration you can see the dorsal peripheral column is
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fractured off and separated leading the palmer prefer column intact
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of course rated rough that you see in cake doesn't usually look like this because the proximal phonics of slumps back
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and it looks a little bit more like that and a crucial factor when planning the operation is to carefully examine
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the contours of the two prefer columns and decide which one is intact and this can be quite subtle
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and then the approaches then made from the side of the broken off column as
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you've got then a ready made access to the bike guy punch fragments
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the broken column can be reflected on the central slip all if palm of the palm
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up late getting access to the type entries can be reduced and then um
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and then um the intact home then remains is uh but just fixation
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if you uh apply compression across the to prefer columns some which is created
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and then the die punch a fragment acts like the for that
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so here's an example uh you can see there are three comes here
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there's the uh central central type ranch and there's two prefer
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columns and if you look carefully this is intact
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and this column that also column is fractured off all of it is quite subtle
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and so the approach here is then from the dorsal uh aspect as of mention
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you can you can lift that fragment hours away hinges on its central slip
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uh reduce the dog punch and then put the screen and uh just simple works like screw
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his uh uh um and at different case you can see his uh
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again three columns is that also call now which is intact
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as the central column that which the type and then there's the whole column there
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which is broken off so in this case the uh the approaches is palmer
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in this case there's a pillow fracture there's no significant i punch elements but there is a t. shape fracture the base
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on the pro cheers dictated by sergio he's and so would also approach would be significantly easier as shown here
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for now consider the surgical approach uh for this we see a fracture we got the apostles location of the base the facts
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there's a central type and special before but also column is intact and so the approach would be palmer
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so his the incision islam that shouldn't which tools exist to make it is midline as possible
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flex mechanisms in the usual way faxes retracted and then the fracture exposed some perversely obviously leading
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the politic to touch the main fragment and we can see that it's quite quite colleges
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the frequency cleaned and and reduced and then with a combination manipulation longitudinal traction plate is
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controlled and and applied and then uh the hondas bristol pompous slab and so the
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patients see the the the the the third person take three and then the things
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mobile noise on the patient is a supply with a a protective resting splints
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and so understanding of the mechanism of injury county planning yes we can be restored release
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imprudent joint mobile yesterday to facilitate multiple to facilitate the modelling and avoid stiffness
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although patient compliance just important with the rehabilitation it's not as crucial as when using frame
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i think that in contrast to condor fractures the opportunity for optimum treat for these last fairly quickly
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and there's really nice for the fractures there's no place for the occasional surgeon choosing these expected good results
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thank you
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