Manual of Fracture Management - Wrist (eBook)

Jesse B. Jupiter, Doug A. Campbell, Fiesky A. Nunez (Herausgeber)

eBook Download: EPUB

2019 | 1. Auflage
524 Seiten
Thieme (Verlag)
9783132582682 (ISBN)

Infos

<p>The <cite>Manual of Fracture Management &ndash; Wrist</cite> examines the management of traumatic and reconstructive problems of the distal radius, distal ulna, and the carpals, the key components of the human wrist. In a rapidly changing field of practice, orthopedic care of wrist fractures and disorders is becoming ever more complex as new technologies, plates, and methods merge and evolve with existing principles and techniques. Ideal for both new and experienced hand, forearm, and upper extremity surgeons, the <cite>Manual of Fracture Management &ndash; Wrist</cite> includes the following key features:<ul><li>Case descriptions and treatment options for a wide variety of fracture and injury types, nonunions and malunions, osteoarthritis, and postoperative complications</li><li>More than 2,000 high-quality illustrations and clinical images</li><li>Access to an online video library of the key wrist surgical approaches.</li></ul></p><p>As with the recently published <cite>Manual of Fracture Management &ndash; Hand</cite>, this publication comprises two major sections: an indepth outline of the major surgical approaches and principles used in wrist surgery, and a detailed description of common to complicated treatment procedures using clinical images from real patient cases. The reader might already have an understanding of the principles of bone healing and basic orthopedic surgery, however, the use of real cases for enhanced illustration adds an immediate and interesting touch to learning and is used to show the recommended procedure and when providing an alternative perspective.</p><p>AOTrauma is proud to bring you this worthwhile and highly informative medical text.</p><p>This book includes complimentary access to a digital copy on <a href='https://medone.thieme.com'>https://medone.thieme.com.</a></p>

Textauszug

2 Carpals

2.1 Scaphoid—nondisplaced fracture treated percutaneously with a headless compression screw

1 Case description

Fig 2.1-1a–b A 26-year-old man fell onto his outstretched right hand during a club soccer game noting immediate acute pain. An examination revealed pain in the anatomical snuff box of his wrist. The AP and lateral x-rays revealed a fracture line across the waist of the scaphoid, however, carpal alignment appeared normal.

Fig 2.1-2a–c The 2-D and 3-D CT scans identified the fracture as having minimal displacement but going through both cortices of the scaphoid in the frontal and sagittal planes (arrows).

2 Indications

Nondisplaced scaphoid fractures

Fig 2.1-3 Percutaneous (minimally invasive) fixation is largely indicated for nondisplaced or minimally displaced fractures of the waist of the scaphoid.

Internal fixation vs nonoperative treatment

In general, internal fixation of fractures is thought to provide effective bone healing in at least the same if not less time than nonoperative treatment, but that the period of immobilization is shortened. Percutaneous treatment brings the advantages of avoiding a wide surgical approach, preserving the palmar ligament complex and local vascularity, and avoiding the extended immobilization required for healing after a wider open exposure.

Readers of this publication are immediately reminded that in some instances of wrist injury, nonoperative treatment is a viable alternative. However, the detailed cases provided throughout this book outline situations where, for those patients, surgical techniques were deemed the more appropriate treatment option.

Imaging

With nondisplaced and minimally displaced scaphoid fractures, conventional x-rays often do not adequately demonstrate the complete fracture configuration. As shown in the case description of this patient, CT scans were therefore performed and are strongly recommended if a percutaneous procedure is planned.

Anatomical considerations

Fig 2.1-4a–e With all scaphoid fractures, the anatomy and vascularity of the scaphoid need to be considered. Close to 80% of the surface of the scaphoid is covered with articular cartilage, which greatly limits the points of entry for fixation devices. An additional constraint is the curved morphology of the scaphoid. This means that it can be difficult to pass a wire or fixation device along the true long axis of the bone, yet this is the implant location that provides the greatest stability and compression. Occasionally, access to the correct distal entry point for a device can only be gained by a limited excision of the overhanging edge of the trapezium.

Vascularity

Fig 2.1-5a–b The blood supply of the scaphoid is derived from two sources. The main source is a group of blood vessels entering the dorsal surface of the distal pole (a). This is the largest contribution to the vascularity of the scaphoid as the dorsal group supplies the proximal two thirds of the bone. However, the proximal pole relies on a retrograde blood flow, a fact that makes this part of the scaphoid more prone to suffer avascular bone necrosis and a consequent nonunion.

A second group of vessels enters the palmar aspect of the distal pole (b). These vessels contribute largely to the vascularity of the distal third.

3 Preoperative planning

Equipment

• Headless compression screw set 2.4 or 3.0

• 1.1 mm K-wires, 150 mm length

• Hypodermic needle

• Osteotome

• Image intensifier

Patient preparation and positioning

Fig 2.1-6 Before starting the procedure, re-examine the fracture pattern under an image intensifier. Be sure that the fracture is suitable for a percutaneous technique and that no secondary displacement has occurred. Position the patient supine and place the forearm on the hand table. By abducting the patient’s shoulder it is possible for the surgeon and the assistant to sit on either side of the hand table. A nonsterile pneumatic tourniquet is used. Prophylactic antibiotics are optional.

4 Surgical approach

Approach

Fig 2.1-7a–b Two approaches exist for percutaneous screw fixation, entering either palmarly (a) or dorsally (b) to reach the scaphoid from either the distal or proximal pole. For the patient in this chapter, the palmar approach was used, entering through the distal pole of the scaphoid.

Hyperextend the wrist

Fig 2.1-8 To assist in the approach, place a rolled towel or bolster under the wrist and hyperextend it. The use of the support helps access the correct entry point for a guide wire.

Mark the skin

Fig 2.1-9 It can be helpful to mark on the skin the position of the scaphoid, the palmar rim of the distal radius, and the level of the scaphotrapezial joint.

Skin incision

A stab incision of 5–10 mm is made distally to the scaphotrapezial joint. Deepen the incision through the subcutaneous tissues by blunt dissection then incise the capsule of the scaphotrapezial joint. The distal pole of the scaphoid is now accessible for insertion of a K-wire, which will be used as a guide wire.

5 Reduction

Determine insertion point for the guide wire

Fig 2.1-10a–b The correct entry point for the guide wire is the center of the distal pole of the scaphoid. However, to get proper access, it may be necessary to remove the palmar ridge of the trapezium with an osteotome or a bone nibbler/rongeur. This reveals the distal pole of the scaphoid and allows the path of the guide wire to be made more centrally within the bone.

Fig 2.1-11a–b Use a hypodermic needle to determine the insertion point radiologically before inserting the guide wire.

Insert the guide wire

Fig 2.1-12a–c The guide wire should be inserted through a drill guide (a). If no drill guide is available, use a protective sleeve. The position of the wire should be as perpendicular as possible to the fracture line (b–c). In oblique fractures, this principle may have to be compromised. Do not penetrate beyond the proximal cortex of the scaphoid.

Fig 2.1-13a–c The guide wire was inserted at the confirmed entry point.

6 Fixation

Measure screw length

Fig 2.1-14a–b Two methods can be employed for measuring the desired length of the headless screw. Insert the dedicated measuring device over the guide wire, through the drill guide, which must be firmly positioned on the tubercle for a reliable measurement (a). Alternatively, if the dedicated measuring device is not available, take another guide wire of the same length and place its tip onto the bone at the insertion point (b). The difference between the protruding ends of the two wires indicates the length of the drill hole for the screw. Subtract 2–3 mm to determine the screw length.

Drilling

Fig 2.1-15 Use only the dedicated drill bit. A power drill will exert less force on the fragments than manual drilling and will reduce the risk of displacing the fragments. A small power drill with slow rotation is the preferred choice. Use saline solution to cool the drill bit in order to minimize thermal injury. Check the position of the tip of the drill bit under image intensification.

Select the screw

Fig 2.1-16a–d Select the appropriately sized cannulated (ie, hollow) headless compression screw (a–c). The selected screw is inserted into the internal thread of the compression sleeve (d).

Insert the screw

Fig 2.1-17 The screw and compression sleeve are inserted over the guide wire.

Fig 2.1-18a–c The screw is tightened until sufficient compression is achieved.

Fig 2.1-19a–b The cannulated screwdriver is inserted. The compression sleeve is held still, using the thumb and index finger to firmly hold the compression sleeve, as the screwdriver turns the screw and advances it out of the compression sleeve and into the bone. Compression is maintained by the compression sleeve during this action.

Advance and countersink the screw

Fig 2.1-20a–c The screwdriver has three colored markings that are visible at the edge of the compression sleeve. The green mark indicates the screw is still fully retained within the compression sleeve (a). The yellow mark...

Produkt-Details

• Erscheint lt. Verlag: 25.4.2019
• Verlagsort: Stuttgart
• Sprache: englisch
• Themenwelt: Medizin / Pharmazie ► Medizinische Fachgebiete ► Orthopädie
• Schlagworte: fracture and injury types • Malunions • Nonunions • Osteoarthritis • Postoperative Complications
• ISBN-13: 9783132582682 / 9783132582682