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A-1285 Acute scaphoid fractures when and how to fix
Hermann Krimmer, Germany
Wednesday, June 13, 2018 · 2:48 p.m. · 14m 47s
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thank you have ah now we move on now we fall closer concentrate on one
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won't insist pay for it maybe we have some overlapping concerning diagnostic but
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but also i want to give you some advice concerning indication uh first of all
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what's doesn't move can you check
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okay my disclosure and first of all it makes sense to speak
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about says cave with because you see a lot of problems
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you can see a nonunion my union uh late stages
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of the deformity it changes and also technical failures
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and first of all we have to ask why we still see such a
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huge number of monuments we have c. t. m. r. i. v. f.
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about screws but we still see a lot a huge number of non unions
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and then we have to really ask what's the reason for that
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and of course we have seen does a major reason not
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up there has been seen this diagnosis very conservative treatment
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but in reality it's only one so that it it wasn't
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seen by a doctor so that means miss diagnosis
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and fate conservative creature and our major problem and for that reason we have to focus on it
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said we really have a standardised procedure to avoid these problems
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and first of all we have to keep in mind we have to
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deal with young patient completely different to this rages fact just we
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have nature say or the population and sees young people
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need adequate treatment say can't afford to where
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two three or four months a long on cost was was pasta and
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first of all when the patient comes in with a tenderness at this restaurant
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we have to look for it and we have to check if there
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is a tenderness and snuff box what tennis that's approximate poll
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if this is not a case set and reliability is that really have
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a skateboard fracture is very rare and send we can't stop
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and we can give them a bandage or some tracks but if that's the case send we have to go for that
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and the problems was expanded to meet we already it hurts it
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means it depends on the position of says cave wait
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when we want to detect a fracture and for that reason you need
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apart from the p. a. and the letter of you at least three
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on a deviated it use it needs a statue of you
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and stature view has nothing to do with the position of service it's
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based on a publications it already exists thirties that you can see user origin and i'll take it
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and what shall we do if you do have says haitian tenderness into stuff box
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even under magnification no signs of a fracture and then usually is
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a discussion starts m. r. i. s. s. c. t.
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and nowadays the answer should be very soon but that means we have to deal
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with the ball on c. t. v. is the most specific to will
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in congress to m. r. i. which is the most sensitive but not specific
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and so of course number one is a high resolution c. t.
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and only if there is that outputs and we have to uh add uh and
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rye you can see how long it would you know to the axes
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and then you can reviews is on display skate would fracture
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and of course you can't read conservatively or the operative
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if you want to have a remote relaxation quality o. c. c. t. scanning it's really sometimes a problem
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you need a long way to denote with the axis of
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course nowadays is a really high resolution c. t. v.
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you can reconstruct or close by a computer software but you must be a way as it it's
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really done long b. today in order to the access and it's it's not a case
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saying you have a problem and you really can't miss the diagnosis this was the paper poppy some years ago
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this was a a young man who came with tenderness snuff box in the c. t. scan last time and
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then you see here it's not wanting to you know to the access and what was the case
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six weeks later he came with this pattern that means established a really
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non fracture healing and does of course need surgery
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and the reason for said is that you don't can't overlook skate would freak just by c. t. scan
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the answer is you can overlook you buy a wrong c. t. scan if it sometime in a right manner
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and another that it wanted show secede key thirty also
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helps you for decision making you can see here
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that they're the hyatt suspicion for a scapegoat fracture you see is a small community area
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but if you go for an hour i of course you see the fracture
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that means the signal loss and the t. wanting itching and enhance mine into fats that meeting
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but it's not really very helpful to decide should we go for operative treatment or conservative friedman
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and when you make your c. t. scan and you see this coming you did area on
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the pond at all the speck of course you would recommend this patient cool for surgery
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and here we yeah if you always already detects a fracture in a simple p. a. view
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then it's usually not a fracture goal for c. t. scan
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and then you see this is a nonunion and when you try to fix it targeting usually
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you will fail and the same is here that's not a fracture that's a non union
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and because sometimes the people like for patients like this is sent to you
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as a fracture is is uh is that they should not union
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finally m. r. i. of course it's had full insect cute stage
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so it means if you have a negative enter i it
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really exclude escape which fracture but m. or high is not suitable
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for follow up because it's such a pattern freezes enhancement can stand for a delayed union
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it's the same way as for a heat a fracture so for follow up m. r. i. is not you did
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so now we have to decide what we do with our skateboard fractures yet detected
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and then we need to get some kind of a classification and this should be treated in place that means
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stable fracture we can't read conservatively unstable fractures we should treat operative three
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and it was tim rabbit who gave us some tool for a
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decision making this is classification they between stable and unstable fractures
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problem was this classification said it was based on playing radio graph
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because at that time c. t. scan wasn't very popular
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and for that reason the modified a little bit since last iteration and we still mean
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if we have a complete fracture through so waste it's still a stable fracture
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despite the fact that said it's complete but it still stable and it's you two before conservative treatment
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all the also fractures with gaps welcoming you to dara should be fixed
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and the proximal poll fracture it's tights affective say are dislocated out not should
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always fixed because of the problems is that a lot of thought
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and concerning conservative treatment if you really differentiate between stable and
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unstable there is no more need for a long cost
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and conservative treatment nowadays should be done by a shot i'm cost
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the discussion uh actually includes a somber not we don't follow it
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be due to some because it makes us safer for us
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and makes it also more reliable from patients point of view
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and after six week we should go for uh
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check up this uh radio graph and not only p. a. and lot read we always need at least the statue of you
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and if there is any doubt we should go for a. c. t. scan and think about two prolonging signal
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below station but no more than up to eight weeks and we have to switch or for operatives actually
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concerning the problems is operative procedures it's well
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known set the rubber their respective
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into pastas operative surgery because we didn't hats adequate imply confiscate would fracture
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and this was a big change in the end of the seventies
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meant team of but came with his that lets bone screw
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but they had which has the advantage that we can completely put it into the bone
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and actually this is the first generation as a principle of server but screws and
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for placement at set times to me in open approach and using the chip
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then came up so the second generation of a headless points to sit back and you late
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and nowadays we are working is is so it can or asians that means
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yeah self cutting self thrilling and a calculated and set
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makes life was the church and it's a surgeon
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really much more easier and we have to implants available uh depending on the fraction size it
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means a regular size that's ahead is two four millimetres and the media that's cool
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and all these problems with the k. whereas are now solved
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because in the past when we we have to trail
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that was always a problem says you're okay whereas sticks out for that reason we had to put
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it in the rate you since and sometimes they're more spending breaking and all the other things
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and to avoid these problems that means wrong position of
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schools it's very important to have a standardised technique
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and so the first step is really set you check your
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placement of the k. i. k. y. at directly
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and uh it's rate control to avoid all these problems it makes no sense to put
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in the k. but to actually get to correct it it can check it
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that means all of all the time most of us each just to bring your
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x. ray machine in this position opposite as a surgeon and it stays
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during so surgery and then you really mark us to teach on
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and then it's very helpful to have a special instrumented way you
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can't endurance yes icky chimed in precisely place you okay wire
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and as we have said thrilling and cutting salaries no more need for anything else
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and if it's the correct position you cause just can insert you'll screw
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and post operative treatment uses patients still have complaints
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we give him a cost at least one or two weeks if they have
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no complaints is the next day he believe it is out any cost
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and this should be the position of the screw screw blanks it's always
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a problem because it's not that easy to measure it precisely
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but it would be important to keep in mind usually it's twenty two to twenty six never use a surgery
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really need a screws because when you really have some problems that exam sticks out it's a dog aspect
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and screw position is also very important here on think okay so it looks quite of cases
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screws insert a bone that's the direction is completely wrong you see already said losing it
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because this will end up in a non union and reason is that the
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angle cisco who is not in the right position that mean it's approximate
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a fragment is only catch on one or two millimetres and this will end up and this is the
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correct that position you can see here uh what happens if this is not in the correct position
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so minimal invasive technique if it's done in a proper way it's a safe taste make
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it has not one hundred percent body really have a good a healing rate and
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limits for minimal invasive fixation ca dislocation body lite diagnose is
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usually our limit is about to a four weeks apart
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then the golf open surgery is an example for weeks post from
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our you can see use the c. v. a. dislocation
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and then you go for surgery you you you just joysticks putting a bone graft and then
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of course you have to do it by an open approach is you can't see yet
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usually when we have can you lady screws you always can breeze serves
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upon my ligaments says no money to to cut it completely
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because this enhanced you stability and being proves you say healy
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french also proximal the third say need precisely imaging as you can
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see here because otherwise there's a major reason to overlook them
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and then of course decision making is clear goal for surgery and
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the proof we're still an open approach you can do it for good times sleep but
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we feel more say than open approach because you don't have caught import ligaments
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and then you have a direct over you can see the fracture line and then to put in your k. y. s.
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to avoid sees problems which because this is very common said you ought to fall on highly it's very
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uh out for to use some landmarks is for example wrong position and
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then you can go if you haven't abducted some you go directly on the pace of sunday bad
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this is the direction you should do you feel that's too far regularly but this
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is the correct position and then you'll okay where is just in that
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direction you want to have it and then you can putting the screws screws
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things usually is between eighteen twenty two meters your again another example
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so in summary precise diagnostic is very important and especially
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look for the quality of u. c. t. scan
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and return pays classification and the sender dust operative technique
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and a c. t. is mandatory or ways to justify conservative treatment
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and if you have an ogre risen fractures approximate assert no doubt about say need surgery
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all the others the t. t. if it's unstable operative if it's done minimal invasive
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two weeks elastic bandage ten six weeks the load the mob
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and if it's stable thing you can go for conservative if only mobility
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station is necessary you also can call for minimal invasive surgery
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