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Re: Огнестрельный перелом луча
Tom DeCoster 18 Март 2004, 12:09
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This patient has a radius shaft segmental fracture with nonunion, healed soft tissue with scar, nerve and probably tendon injuries but a well perfused hand, probably not infected and an intact ulna.
This would most commonly be treated with plate fixation of the radius shaft and the bone would typically heal in good position and give the best chance at optimal recovery of the various soft tissue problems.
Although one could argue for intramedullary fixation on a theoretical basis, plates work very well on the radius shaft in both practice and theory.
At 5 months post injury you could either reduce the distal nonunion and span the intercalary segment (4 screws in the proximal and distal fragments) accepting some imperfect alignment at the proximal fracture site or take down the "nascent imperfect" union at the proximal fracture site. Although the fracture may be "healed", by carefully scraping away the callus you can typically develop the original fracture line and improve the reduction in the manner of Jupiter and distal radius "nascent" malunions. The callus will provide adequate bone graft to fill the apparent small bone defect at the distal nounion site.
Restoring length, rotation and stability immediately and obtaining ultimate bone healing will greatly enhance the potential for soft tissue recovery. (in contrast to accepting a chronic nonunion around some kind of small intramedullary device).
To me, there is a good treatment option available with reasonably good chance of success and no need to try something innovative.
TD
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Re: Огнестрельный перелом луча
Alexander Chelnokov 19 Март 2004, 15:41
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TAC> Although one could argue for intramedullary fixation on a theoretical basis,
TAC> plates work very well on the radius shaft in both practice and theory.
Recent years we nail without site opening all shaft forearm fractures by individually customized titanium nails.
TAC> Restoring length, rotation and stability immediately
By a quite invasive open mobilization and reduction...
So it seems reasonable to restore length and axis gradually.
A distractor was applied, anв the x-ray is performed after strong manual traction.
TAC> and obtaining ultimate bone healing will greatly enhance the
TAC> potential for soft tissue recovery. (in contrast to accepting a
TAC> chronic nonunion around some kind of small intramedullary
Proper alignment and good stability is reachable by a closed nail, at least of that sort we use. Anyway final result will mostly depend on hand function/sensitivity rather than radial (non)union. Which itself didn't bother the patient.
TAC> To me, there is a good treatment option available with reasonably
TAC> good chance of success and no need to try something innovative.
If the the stable aligned radius can be reached without excessive incision and open mobilization why neglect the option?
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Re: Огнестрельный перелом луча
Отправитель: Tom DeCoster 19 Март 2004, 19:43
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All good points you make.
I do think hand and soft tissue recovery would be enhanced by solid bone union of a reasonably reduced radius. Your mention of accepting nonunion with a "shaft endoprosthesis" suggests that you might also be concerned that IM nailing might have a resonably high persistent nonunon rate. I suspect it would be higher than with plating. But plating has it's drawbacks, notably extensive dissection as you noted.
By the way, yesterday I saw for the first time, a titanium roof being put on a house.
TD
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Re: Огнестрельный перелом луча
Отправитель: Dr. T. I. George 19 Март 2004, 19:55
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Alex,
I have not been following this discussion in detail. However would like to give a comment on your statement.
AC : If the the stable aligned radius can be reached without excessive incision and open mobilization why neglect the option?
Having put the patient on ring fixator, the intervention required for nerve exploration, repair and grafting are delayed till the fixators are removed.
This is bound to affect the end result of nerve repair/ grafting. If an open procedure like plating was resorted to, then nerve intervention also could have been taken up simultaneosly and total recovery period could have been shorter with probably a better end result.
Dr. T. I. George.
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Re: Огнестрельный перелом луча
Отправитель: Alexander Chelnokov 19 Март 2004, 20:07
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t> Having put the patient on ring fixator, the intervention required for nerve
t> exploration, repair and grafting are delayed till the fixators are removed.
Exactly.
t> This is bound to affect the end result of nerve repair/ grafting.
Do you suppose the end result would be markedly affected if the fixator was applied in 5.5 months since the initial injury, and is to be removed within 2-3 weeks, in 6 months?
t> nerve intervention also could have been taken up simultaneosly and
t> total recovery period could have been shorter with probably a
t> better end result.
I would expect a better result if nerve/vessel repair would be
performed by a skilled team which is not available in my settings.
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Re: Огнестрельный перелом луча
Отправитель: Dr. T. I. George 20 Март 2004, 10:41
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Dear Alex,
If the fixator is going to come out in 2-3 weeks time, then it should not make a difference. If you are planning to internally stabilise at this time, then are you sure that the nail will be sufficient for the subsequent procedure?
I agree that it makes a difference to get an experienced person to do the nerve and vascular repair. If your centre has sufficient trauma load it may be worth to send someone for this training and he/she will be an asset to the team and centre.
Dr. T. I. George
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