span scan plan2 - aado · span preliminary reduction of gross mal-alignment immobilisation of the...

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Management of Management of PeriPeri--ArticularArticular FracturesFractures

Span Span -- Scan Scan -- PlanPlan

WY ShenWY Shen

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2 © WY Shen

SpanSpan

Preliminary reduction of gross malPreliminary reduction of gross mal--alignmentalignmentImmobilisation of the involved jointImmobilisation of the involved joint

Synthetic cast, applied and then Synthetic cast, applied and then bivalvedbivalvedSpanningSpanning External External FixatorFixator

Spanning could be achieved with cast or external fixator.

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Purpose of Purpose of ““SpanningSpanning””

Rest and observe the soft tissuesRest and observe the soft tissuesCorrect the gross malCorrect the gross mal--alignment foralignment for

better Xbetter X--raysraysCT ScanCT Scan

Buy time for better planning Buy time for better planning and soft tissue management!and soft tissue management!

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Spanning External FixationSpanning 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.

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Spanning External FixationSpanning External Fixation

Just restore gross Rotation, Axis and Length (in Just restore gross Rotation, Axis and Length (in that order) that order) acrossacross the jointthe jointNo need to be sophisticated or perfectNo need to be sophisticated or perfectPins 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 scanningWill not interfere with CT scanningKeeps virgin field for option of platingKeeps virgin field for option of plating

A A Strategic StepStrategic Step in Highin High--energy energy PeriPeri--ArticularArticular Fractures, and Open FracturesFractures, and Open Fractures

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6 © WY ShenAO Manual, Internal Fixators, 2006

Poor Placement of Clamps will Poor Placement of Clamps will obstruct plain xobstruct 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.

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Spanning Ex FixSpanning 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.

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ScanScan

CT tells a lot more than plain XCT tells a lot more than plain X--rayray

CT gives a far better 3CT gives a far better 3--D picture even D picture even without 3without 3--D reconstruction viewsD reconstruction views

CT allows accurate measurements if you CT allows accurate measurements if you can view it oncan view it on--lineline

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ScanScan

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.

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PlanPlan

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. ((WikipediaWikipedia))

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.

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CircumstancesCircumstances

An Analysis of An Analysis of Fracture type and patternFracture type and patternEnergy level and soft tissue conditionEnergy level and soft tissue conditionFunctional requirementFunctional requirementOverall background Overall background –– multiple injuries, age, multiple injuries, age, jobjob……....What could be achieved, and what couldnWhat could be achieved, and what couldn’’t be t be attainedattained

“Circumstances” as in the definition of “Plan”, include…….

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ObjectivesObjectives

Somewhere betweenSomewhere betweenFull reconstruction Full reconstruction –– anatomical reduction and anatomical reduction and alignment, congruent alignment, congruent articulararticular surfacesurface

Reconstruct alignment, bony framework and Reconstruct alignment, bony framework and ligamentousligamentous stability for later joint replacementstability for later joint replacement

Mangled? Forget about it!Mangled? Forget about it!

Objectives should be set realistically.

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PlanningPlanningNot just about how you put the fragments back Not just about how you put the fragments back togethertogetherChoice of implantChoice of implantDirection of screws and wires Direction of screws and wires ……....Timing and staging of operationTiming and staging of operationDetailed steps and required instrumentsDetailed steps and required instrumentsMaking Plan A and B andMaking Plan A and B and…….. contingency plans.. contingency plansAn 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.

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Plan Plan –– Reduction StrategyReduction Strategy

Indirect reduction techniquesIndirect reduction techniquesSoft tissue preservationSoft tissue preservationRestoring both joint congruity and the mechanical axis

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Plan Plan –– Choice of ImplantsChoice of ImplantsInternal fixation Internal fixation –– traditional buttress / LISS / traditional buttress / LISS / MIPO / other locking plates? Approach?MIPO / other locking plates? Approach?Additional Screws Additional Screws –– CannulatedCannulated? Size? ? Size? Direction? Sequence?Direction? Sequence?External Fixation External Fixation ––

Traditional / Hybrid / RingTraditional / Hybrid / RingCross or not crossing the jointCross or not crossing the jointAdditional 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?

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F/80, Open Injury IIIAF/80, Open Injury IIIA

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Spanned & Spanned & DebridedDebrided

The open wound was debrided and lavaged. The fracture was reduced and held immobilised with a spanning external fixator.

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Fixed without Scanning, Wd Closed, D3Fixed without Scanning, Wd Closed, D3

However, the surgeon was too eager to operate. He did so on Day 3 without any CT.

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PostPost--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.

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M/32, Closed fractureM/32, Closed fracture

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Scanned after Spanning with SlabScanned after Spanning with Slab

The yellow line on the left indicates the level of the axial cut displayed on the right.

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CT showed the # not seen on XCT showed the # not seen on X--RayRay

An unexpected crack was found at the medial malleolus.

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PlannedPlanned

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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.

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TreatmentTreatment

PercutaneousPercutaneous cannulatedcannulated screw fixation for the screw fixation for the medial medial malleolusmalleolus..

MiniMini--open wound over the open wound over the anteroantero--lateral aspect lateral aspect and and cannulatedcannulated screw fixation of the distal tibia screw fixation of the distal tibia fragment. fragment.

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Fixed as PlannedFixed as Planned

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PlanPlan

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. ((WikipediaWikipedia))

Anticipate difficultiesAnticipate difficultiesReflect on your own experienceReflect on your own experience

Remember to plan well!

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Excellent ReviewExcellent Review

High-Energy Tibial Plateau Fractures

Berkson & VirkusJ Am Acad Orthop Surg 2006;14: 20-31

span scan plan2 - aado · span preliminary reduction of gross mal-alignment immobilisation of the...

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