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- 1. 1 1 Management of Management of Peri Peri- -Articular Articular Fractures Fractures Span Span - - Scan Scan - - Plan Plan WY Shen WY Shen
- 2. 2 2 © WY Shen Span Span „ „ Preliminary reduction of gross mal Preliminary reduction of gross mal- - alignment alignment „ „ Immobilisation of the involved joint Immobilisation of the involved joint „ „ Synthetic cast, applied and then Synthetic cast, applied and then bivalved bivalved „ „ Spanning Spanning External External Fixator Fixator Spanning could be achieved with cast or external fixator.
- 3. 3 3 © WY Shen Purpose of Purpose of “ “Spanning Spanning” ” „ „ Rest and observe the soft tissues Rest and observe the soft tissues „ „ Correct the gross mal Correct the gross mal- -alignment for alignment for „ „better X better X- -rays rays „ „CT Scan CT Scan „ „Buy time for better planning Buy time for better planning and soft tissue management! and soft tissue management!
- 4. 4 4 © WY Shen Spanning External Fixation Spanning External Fixation „ Provides stability to restore the limb closer to its normal anatomy and allows faster resolution of soft-tissue swelling than do splints or other forms of temporary immobilization. „ Provides access for wound care and compartment monitoring and offer sufficient stability for early patient mobilization.
- 5. 5 5 © WY Shen Spanning External Fixation Spanning External Fixation „ „ Just restore gross Rotation, Axis and Length (in Just restore gross Rotation, Axis and Length (in that order) that order) across across the joint the joint „ „ No need to be sophisticated or perfect No need to be sophisticated or perfect „ „ Pins and clamps should be placed reasonably far Pins and clamps should be placed reasonably far from the fracture site from the fracture site – – „ „ Will not interfere with CT scanning Will not interfere with CT scanning „ „ Keeps virgin field for option of plating Keeps virgin field for option of plating „ „ A A Strategic Step Strategic Step in High in High- -energy energy Peri Peri- - Articular Articular Fractures, and Open Fractures Fractures, and Open Fractures
- 6. 6 6 © WY Shen AO Manual, Internal Fixators, 2006 Poor Placement of Clamps will Poor Placement of Clamps will obstruct plain x obstruct plain x- -ray and CT! ray and CT! Thus, remember not to position any metal near the fracture site. Otherwise, they will obstruct the view on plain x-rays, or cause severe interference in CT.
- 7. 7 7 © WY Shen Spanning Ex Fix Spanning Ex Fix Berkson et al: JAAOS, 2006 Since the spanning external fixator is a temporary device, it does not matter if it was inserted through the quadriceps. If the fixator is expected to last for more than 5 to 7 days, the transfixion pins should then be removed and inserted from the postero-lateral aspect into the femur, so as not to transfix any major muscle group. The initial fixation need only be very simple, safe and expedient. Stay well away from the fracture site.
- 8. 8 8 © WY Shen Scan Scan „ „ CT tells a lot more than plain X CT tells a lot more than plain X- -ray ray „ „ CT gives a far better 3 CT gives a far better 3- -D picture even D picture even without 3 without 3- -D reconstruction views D reconstruction views „ „ CT allows accurate measurements if you CT allows accurate measurements if you can view it on can view it on- -line line
- 9. 9 9 © WY Shen Scan Scan „ Taking CT scans in addition to plain radiographs affected fracture classification, and thus the surgical plan, in >25% of cases „ Chan et al: J Orthop Trauma 1997. „ Degree of articular depression often is under- appreciated on plain radiographs „ Liow et al: Orthopedics 1999.
- 10. 10 10 © WY Shen Plan Plan „ „ A plan is a proposed or intended A plan is a proposed or intended method of of getting from one set of getting from one set of circumstances to to another. They are often used to move from the another. They are often used to move from the present situation, towards the achievement of present situation, towards the achievement of one or more one or more objectives or goals. or goals. ( (Wikipedia Wikipedia) ) „ „ Anticipate Anticipate „ „ Reflect Reflect difficulties on your own experience Anticipated difficulties and solutions are important ingredients of a plan. The capability of the whole team together is more important than the capability of the individual surgeon.
- 11. 11 11 © WY Shen Circumstances Circumstances „ „ An Analysis of An Analysis of „ „ Fracture type and pattern Fracture type and pattern „ „ Energy level and soft tissue condition Energy level and soft tissue condition „ „ Functional requirement Functional requirement „ „ Overall background Overall background – – multiple injuries, age, multiple injuries, age, job job… ….. .. „ „ What could be achieved, and what couldn What could be achieved, and what couldn’ ’t be t be attained attained “Circumstances” as in the definition of “Plan”, include…….
- 12. 12 12 © WY Shen Objectives Objectives Somewhere between Somewhere between „ „ Full reconstruction Full reconstruction – – anatomical reduction and anatomical reduction and alignment, congruent alignment, congruent articular articular surface surface „ „ Reconstruct alignment, bony framework and Reconstruct alignment, bony framework and ligamentous ligamentous stability for later joint replacement stability for later joint replacement „ „ Mangled? Forget about it! Mangled? Forget about it! Objectives should be set realistically.
- 13. 13 13 © WY Shen Planning Planning „ „ Not just about how you put the fragments back Not just about how you put the fragments back together together „ „ Choice of implant Choice of implant „ „ Direction of screws and wires Direction of screws and wires … ….. .. „ „ Timing and staging of operation Timing and staging of operation „ „ Detailed steps and required instruments Detailed steps and required instruments „ „ Making Plan A and B and Making Plan A and B and… ….. contingency plans .. contingency plans „ „ An opportunity to discuss with the patient when An opportunity to discuss with the patient when mentally and emotionally more settled. mentally and emotionally more settled.
- 14. 14 14 © WY Shen Plan Plan – – Reduction Strategy Reduction Strategy „ „ Indirect reduction techniques Indirect reduction techniques „ „ Soft tissue preservation Soft tissue preservation „ Restoring both joint congruity and the mechanical axis
- 15. 15 15 © WY Shen Plan Plan – – Choice of Implants Choice of Implants „ „ Internal fixation Internal fixation – – traditional buttress / LISS / traditional buttress / LISS / MIPO / other locking plates? Approach? MIPO / other locking plates? Approach? „ „ Additional Screws Additional Screws – – Cannulated Cannulated? Size? ? Size? Direction? Sequence? Direction? Sequence? „ „ External Fixation External Fixation – – „ „ Traditional / Hybrid / Ring Traditional / Hybrid / Ring „ „ Cross or not crossing the joint Cross or not crossing the joint „ „ Additional minimal internal fixation? Additional minimal internal fixation? „ „ Bone graft? / Bone Substitute? Bone graft? / Bone Substitute? „ „ Fluoroscopy alone? / Arthroscopy as well? Fluoroscopy alone? / Arthroscopy as well?
- 16. 16 16 © WY Shen F/80, Open Injury IIIA F/80, Open Injury IIIA
- 17. 17 17 © WY Shen Spanned & Spanned & Debrided Debrided The open wound was debrided and lavaged. The fracture was reduced and held immobilised with a spanning external fixator.
- 18. 18 18 © WY Shen Fixed without Scanning, Wd Closed, D3 Fixed without Scanning, Wd Closed, D3 However, the surgeon was too eager to operate. He did so on Day 3 without any CT.
- 19. 19 19 © WY Shen Post Post- -Op. : Closed wd broke down on D8! Op. : Closed wd broke down on D8! Inadequate reduction/fixation at the lateral aspect of the tibial pilon. Worse still, the closed wound broke down. Lesson learned: be patient with management of the soft tissues, especially in old patients.
- 20. 20 20 © WY Shen M/32, Closed fracture M/32, Closed fracture
- 21. 21 21 © WY Shen Scanned after Spanning with Slab Scanned after Spanning with Slab The yellow line on the left indicates the level of the axial cut displayed on the right.
- 22. 22 22 © WY Shen
- 23. 23 23 © WY Shen
- 24. 24 24 © WY Shen
- 25. 25 25 © WY Shen
- 26. 26 26 © WY Shen CT showed the # not seen on X CT showed the # not seen on X- -Ray Ray An unexpected crack was found at the medial malleolus.
- 27. 27 27 © WY Shen Planned Planned 1 2 1. Fix the undisplaced # 2. Percutaneous clamp + Mini-open Screw The plan was to insert cannulated screws. First to fix the undisplaced medial fracture. Then the second one to fix the antero-lateral fracture, after reducing the “trap door” fracture through a small wound – to free and protect the anterior tendons, and to achieve reduction.
- 28. 28 28 © WY Shen
- 29. 29 29 © WY Shen
- 30. 30 30 © WY Shen Treatment Treatment „ „ Percutaneous Percutaneous cannulated cannulated screw fixation for the screw fixation for the medial medial malleolus malleolus. . „ „ Mini Mini- -open wound over the open wound over the antero antero- -lateral aspect lateral aspect and and cannulated cannulated screw fixation of the distal tibia screw fixation of the distal tibia fragment. fragment.
- 31. 31 31 © WY Shen Fixed as Planned Fixed as Planned
- 32. 32 32 © WY Shen Fixed as Planned Fixed as Planned
- 33. 33 33 © WY Shen M/27, Closed Sprain Injury M/27, Closed Sprain Injury
- 34. 34 34 © WY Shen Reduced and Spanned with Reduced and Spanned with Dynacast Dynacast Slab Slab
- 35. 35 35 © WY Shen K-wire Scanned / Planned Scanned / Planned
- 36. 36 36 © WY Shen
- 37. 37 37 © WY Shen
- 38. 38 38 © WY Shen
- 39. 39 39 © WY Shen
- 40. 40 40 © WY Shen Screw with washer
- 41. 41 41 © WY Shen Screw with washer
- 42. 42 42 © WY Shen Fixed as Planned Fixed as Planned
- 43. 43 43 © WY Shen Post Post- -Op. Op.
- 44. 44 44 © WY Shen Plan Plan „ „ A plan is a proposed or intended A plan is a proposed or intended method of of getting from one set of getting from one set of circumstances to to another. They are often used to move from the another. They are often used to move from the present situation, towards the achievement of present situation, towards the achievement of one or more one or more objectives or goals. or goals. ( (Wikipedia Wikipedia) ) „ „ Anticipate difficulties Anticipate difficulties „ „ Reflect on your own experience Reflect on your own experience Remember to plan well!
- 45. 45 45 © WY Shen Excellent Review Excellent Review „ High-Energy Tibial Plateau Fractures „ Berkson & Virkus J Am Acad Orthop Surg 2006;14: 20-31