Operative Techniques in Orthopaedic Surgery is the first major new comprehensive text and reference on surgical techniques in orthopaedics. The idea for this text, Key Techniques in Orthopaedic Surgery, came directly as the authors or the text attempt to define the listed operative techniques as rep-. Operative Techniques in Orthopaedic Trauma Surgery provides full-color, step-by -step explanations of all operative procedures in orthopaedic trauma surgery.
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Operative Techniques in Orthopaedic Surgery (Four Volume Set) rar (part4); размером ,39 МБ; содержит документ формата pdf. Read the latest articles of Operative Techniques in Orthopaedics at In Press, Corrected Proof, Available online 29 July ; Download PDF. EditorialFull text . RUSH: Operative Techniques in Orthopaedics article for proofing (# ) a printout of the PDF file and fax this to Nick DeAngelis (fax #: ), or mail to . Professor of Surgery, Division of Orthopaedic Surgery, Dalhousie Univer-.
The May field headrest allows the patients head and neck to be slightly extended and rotated to the nonoperative side giving better access to the clavicle particularly in the medial one-third. The patients head is further secured to the May field headrest by circumferentially wrapping it with a large Kerlix roll. The ipsilateral arm rests on a standard arm board, which is adducted or rotated parallel to the OR table Fig.
The head foot of the table is then elevated 15 to 20 degrees. The C-arm image intensifier is brought in to ensure that the clavicle will be well visualized during the procedure Fig. Because the metal supports in most operating room tables partially obscure the field of view, it is often necessary to tilt or rotate the C-arm a few degrees to achieve satisfactory images.
Prior to the surgical prep, the upper chest wall and clavicular regions can be shaved if necessary. The entire clavicle, shoulder, neck, chest wall, and upper extremity are prepped and draped. The image intensifier must be sterilely draped and isolated as well. The sterile surgical field should encompass the entire upper extremity including the clavicle and the ipsilateral acromialclavicular and sternoclavicular joints Fig.
At this point in time, a surgical time-out is called, and all members of the surgical, nursing, and anesthesia teams must concur with the patients name, medical record number, and correct side and site of surgery, before the procedure begins. Unless there are specific cardiopulmonary contraindications, the anesthesiologist is asked to maintain the patients sy stolic blood pressure below mm Hg.
This small but helpful step can reduce blood loss during the case since a tourniquet is not employ ed. Patient positioning for clavicle surgery. The patient is prepped and draped.
Surgery With a sterile marking pen, the superior and inferior borders of the proximal and distal fragments of the clavicle are marked on the skin, and an appropriate length incision is centered over the fracture site Fig.
In large, obese, or very swollen patients, the clavicle may be difficult to palpate. In these cases, the C-arm image intensifier can be used to localize the fracture site for the skin incision. A transverse incision is made parallel to the clavicle and deepened through a subcutaneous tissues. Meticulous hemostasis is obtained with electrocautery.
Several sensory clavicular nerves cross the surgical field longitudinally. When possible, these nerves should be preserved as they provide sensation to the infraclavicular portion of the chest wall. In many cases, however, one or more of these nerves need to be divided to facilitate exposure and fixation. Patients should be counseled that some numbness on the chest wall may occur after surgery.
The proximal clavicular fragment is exposed first Fig. It is usually quite prominent, subcutaneous, and is relatively straight forward. At the fracture site, the soft tissues and thin periosteum are elevated several millimeters to expose the bone end. There is a relatively avascular plane between the deltoid anteriorly and trapezius posteriorly that can be developed down to bone. The soft tissues should only be elevated to accommodate the plate medially.
The proximal fracture fragment is exposed first. The fracture site is now exposed, and the provisional hematoma is evacuated and copiously irrigated. The distal fragment is visualized at the fracture site and is ty pically shortened and displaced downward and forward beneath the proximal fragment.
To better expose the distal fragment, a small Hohman retractor or serrated reduction clamp is placed just distal to the fracture site, which elevates the bone into the wound for careful subperiosteal dissection.
In patients with comminuted fracture patterns, reduction and fixation of one or more butterfly fragments may be necessary to achieve stable fracture fixation. In my experience, cortical fragments measuring 15 to 20 mm in size usually need to be incorporated into the fixation construct. Care should be taken to preserve the soft-tissue attachments to these fragments in order to avoid disruption of their blood supply.
In many patients, there is a large anterior butterfly fragment containing fibers of the deltoid muscle. Depending on the fracture geometry, this fragment should be reduced and temporarily fixed to either the proximal or distal main fragment with Kwires or a small pointed reduction clamp Fig.
Because these fragment s are relatively small, 2. Comminution that is too small or not critical for mechanical stability are removed if they are devoid of soft tissues and retained as bone graft if there are meaningful soft-tissue attachments.
Other large butterfly fragments are similarly reduced and fixed. Using small-reduction forceps on the main proximal and distal fracture fragments, the fracture is reduced by distraction and translation. In simple noncomminuted transverse or short oblique fractures, reduction with restoration of cortical continuity often produces sufficient stability to allow removal or repositioning of the reduction clamps to apply the plate.
With stable fracture patterns, compression of the fracture through the plate is desirable. In more unstable fracture patterns, a neutralization or spanning plate is preferred. In highly comminuted clavicle fractures, bridging plates that restore length, alignment, and rotation, while preserving the soft-tissue attachments, remain the treatment of choice Fig.
Implants There are two distinct schools of thought regarding plate placement. The plate can be placed either anteriorly or superiorly because biomechanical testing has not demonstrated an optimal position. Proponents of the anterior plate argue that it is safer, since the screws are directed from anterior to posterior, thereby avoiding the lung and the neurovascular structures.
Furthermore, it reduces the number of patients who may require sy mptomatic hardware removal.
On the other hand, anterior plating requires additional dissection of the deltoid muscle, particularly distally, and it is more difficult to fit the plate on the thin anterior surface of the distal fragment.
With anterior plating, the insertion angle for screws in the plate may be difficult to achieve in large patients or women with generous breasts. Alternatively, surgeons who favor superior plating cite easier surgery and fixation with possibly improved biomechanics. The disadvantages with this technique are a greater risk to the important adjacent structures when drilling and the higher incidence of sy mptomatic hardware.
Regardless of the plate position, a plate of adequate strength is required. One-third of tubular plates and minifragment plates as stand-alone implants are rarely indicated in adults. Most studies support the use of thicker small fragment plate with 3. In y oung patients with excellent bone, nonlocking cortical screws are usually adequate. In older patients with compromised bone stock, or in any fracture with a short proximal or distal segments, locking screws unequivocally improve strength of fixation.
A minimum of three screws six cortices should be placed in the major proximal and distal fracture fragments Fig. Frequently, one or more screw holes in the plate are left empty at the level of the fracture. With fractures involving the distal one-fourth of the clavicle, special precontoured periarticular clavicle plates may be helpful.
These implants have a flared or enlarged lateral end to the plate and accept four to six 2.
However, due to the wide variation in clavicular morphology, these plates do not alway s fit well. For most middle third fractures, I prefer to contour a straight pelvic reconstruction plate that allows me to precisely match the patients anatomy Fig.
Invariably this requires a double bend to accommodate the S-shape of the clavicle and slight twist in the plate. However, many surgeons favor the precontoured plates for diaphy seal fractures. Prior to closure, intraoperative fluoroscopy is used to assess the quality of the reduction as well as to ensure screws are of appropriate length. Sy nthes Paoli, PA 3. In comminuted fractures when there are small residuals defects around the fracture site, 5 cc of demineralized bone matrix putty is packed around the fracture site to augment healing.
The wounds are copiously irrigated and closed in lay ers. The deep soft-tissue closure should cover the plate. Drains are not routinely utilized. In all patients, a careful subcuticular plastic closure is done. A firm pressure dressing is applied, and the affected arm is placed into a sling.
Postoperative Management In healthy patients with uncomplicated surgery whose pain is minimal or moderate can be sent home on the day of surgery.
In older patients, and those with complex fracture patterns, prolonged surgery, severe pain, or medical comorbidities are admitted to the hospital overnight and discharged on post-op day 1. Hospitalized patients receive two postoperative doses of an intravenous cephalosporin antibiotic when there is no allergy.
Except for the rare open fracture, no additional intravenous or oral antibiotics are administered. Virtually all patients require strong oral analgesics for the first week or two following surgery. Patients are seen in the out-patient clinic approximately 7 to 9 day s after their surgery.
Sutures are removed, and a radiograph of the clavicle is obtained and reviewed with the patient. The surgical incision is generally left open, and patients are allowed to bathe or shower and get the incision wet. When stable internal fixation has been achieved, patients are allowed to remove their sling for activities of daily living such as eating, grooming, and dressing.
Most patients usually wear a sling for 2 to 4 weeks and then discard it. Phy sical therapy is not routinely employ ed as the glenohumeral joint is not affected, and most patients are moving their shoulder within the first 2 to 3 weeks.
Patients with office jobs are allowed to return to work within 2 or 3 weeks flowing surgery.
On the other hand, return to work for patients with phy sically demanding jobs must be delay ed a minimum of 6 to 8 weeks and often up to 12 weeks. After the first postoperative visit, patients are followed at monthly intervals until the fracture has healed radiographically, which can range from 8 to 16 weeks. Patients are allowed to return to noncontact sports such as walking, jogging, and cy cling at 6 weeks. Participation in more vigorous sports such as soccer, tennis, and baseball is delay ed until 10 weeks postoperatively.
Return to football, rugby, judo, hockey, etc.
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