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Re: Огнестрельный перелом луча
Bryan Neal 15 Март 2004, 19:46
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Presumably not infected.
Picture of forearm shows possible thumb flexion contracture (could be positional) but definite flexion contracture of the little finger. Is this ulnar clawing (fixed verse flexible deformity) or extrinsic flexor contractures.
Location of scar/incision (ulnar) suggests possible ulnar nerve injury.
Concerning noninfected radius shaft nonunion: explore with internal fixation (I would use a locking 3.5 mm plate but use a standard compression plate if not available). Bone grafting (possible BMP but costs $5,000 in the US). Explore all involved nerves, repair if possible, graft if not. Nerve exporation/repair/grafting can be done at same time.
Tendon transfers possible much definitely at later date, only after bone union and assesmnet of residual nerve healing.
Good luck.
Sincerely and respectively,
M. Bryan Neal, MD
Arlington Orthopedics and Hand Surgery Specialists, Ltd.
1100 W. Central Road, Suite 304
Arlington Heights, Illinois 60005
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Re: Огнестрельный перелом луча
Alexander Chelnokov 15 Март 2004, 21:15
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AAC> Location of scar/incision (ulnar) suggests possible ulnar nerve injury.
Yes, fingers IV-V are also not sensible.
AAC> Concerning noninfected radius shaft nonunion: explore with internal fixation
AAC> (I would use a locking 3.5 mm plate but use a standard compression plate if
AAC> not available).
Why not closed nail? Tissues are rigid, excessive scars, and the segmental piece looks malunited to the proximal radial fragment, so it would cause a problem with plate placement. The nail is safe and low invasive, and it would allow not to care about the union.
AAC> Bone grafting (possible BMP but costs $5,000 in the US).
8-[ ] Wow! The nail is much cheaper. If one can spare the money would he obtain its part? ;-)
AAC> Explore all involved nerves, repair if possible, graft if not.
AAC> Nerve exporation/repair/grafting can be done at same time.
We leave such surgeries either for hand surgery clinic or neurosurgery center.
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Re: Огнестрельный перелом луча
Отправитель: Bryan Neal 16 Март 2004, 17:26
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Thanks for the note.
Plating, I think, would give a more rigid contruct than IM nail. Plating also allows for nerve exploration and bone grafting, all at the same time. IM nailing certainly would allow closed treatment but it is possible that one is not
able to obtain intramedullary placement of a rod without actually opening.
Sometimes I have placed a IM rod in the radius shaft and found the contour actual distracted the fracture site. IM rod is an option although I would not use it.
The BMP (Bone Morphogenic Protein) is a synthetic growth factor to stimulate bone growth. Very expensive, $5,000 for small amount. very new. I have used only twice.
Good luck.
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Re: Огнестрельный перелом луча
Отправитель: Evgueny Tchekashkine 17 Март 2004, 08:28
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Hello Bryan,
BMP is attractive but too expensive option.
.
Have you got any data proving clinical advantage of using BMP vs autologous cancellous bone graft.(besides the obvious donor site pain problem)?
I will appreciate if you could share it at ORTHOFORUM.
Some of the surgeons prefer straight forward tendons transfer to long standing expectation of motor and sensory recovery after nerve repair or
grafting.
I wonder what do you think about such approach and whether there are any established regulations for such kind of cases in your healthcare system.
Kind regards,
Evgueny Tchekashkine
orth.dept., WCH,
Windhoek, Namibia
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