[MUSIC] [MUSIC] [MUSIC] [MUSIC] [MUSIC] [MUSIC] >> Let's move these two up so that we can deal with them now. (KNOCK) >> Excuse me. We have a new female patient who fell over onto her right arm. >> Stay seated, I am on my way. >> Thank you. >> Hallo. >> Hallo, doctor. Unfortunately, I can only shake hands with you by using my left one. The right one is causing me so much pain. I fell over. >> My name is Kirchhoff and I am from the Trauma Surgery Department. So, you fell over? Why? >> I went walking with Rüdiger and then... It is quite slippery outside. I slipped and then fell directly onto my hand and Rüdiger was also so shocked at seeing what had happened. Und der Rüdiger, der hat auch so einen Schock bekommen. >> Rüdiger? Is he here as well and also needs to be treated? >> No, no, Rüdiger is my German Shepherd. My shepherd dog is so large and so and so feisty and was pulling on the lead so strongly that I slipped. >> And is it your forearm or your wrist which now hurts the most? >> My wrist. This area really hurts a lot. For us to gain a better understanding of radius fractures, let’s run through the anatomy once again: the wrist is composed of the distal radius, the distal ulna, the scaphoid bone and lunate bone. Strength is transferred from the hand to the forearm via three functional columns: the radial column consists of the styloid process and the scaphoid bone, the central column of the ulnar section of the radius, the lunate bone and the articular surface of the ulna and the ulnar column: the distal ulna together with the ulnocarpal complex. This slide once again makes clear the 3-column concept according to Rikli and Regzzoni. If the wrist is in the 0° position, then 80% of the strength flows via the central column. What is clear is that changes in the positions of the joint can lead to arthrosis. Assessment of the joint position is made via the Böhler angle, a radial inclination of the articular surface by 10° and palmar-dorsal inclination by 5°. In the event of intra-articular step formation of more than 2-3 mm, arthrosis can occur very rapidly. This slide shows the Böhler angle once again. The angle of the base of the radius is shown on the left side, the palmar inclination on the right. Radius fractures are the form of fracture most frequently experienced by human beings. Over 200,00 fractures per year are estimated to occur in Germany. There are two age peaks. The first age peak is found between 9 and 18 and the second among people over 50. Comminuted fractures are likely to occur more in patients over 70. >> Can I now have a very quick look at your arm, please? Does that really hurt or is it OK if I touch the arm there? >> No, it is OK, it's OK, yes, mmm. >> OK, good. Does it hurt if I press down here at the elbow? >> No, no. >> Not in any way. >> Can you feel all your fingers? >> Yes. >> Can you carefully move them? Does that hurt? >> That hurts. Yes, it does. Here at the front most likely. >> Yes, it hurts. >> I’m just going to place your arm carefully into my hand. Is that OK if I turn it over or does it hurt? >> Yes, that is OK. >> Does it hurt if I press down here into the anatomical snuff box? >> No. >> Okay. What about this - do you feel any pain with the thumb being compressed? >> No, nothing either. >> That's good, super. I’m not going to examine any further down there at all. We’re now going to take an x-ray, as the arm could of course be broken judging purely from what you have said and how the wrist looks. >> Oh, I see. >> Please now just take your hand, hold it stable and go out the door, turn right and then walk ten meters. rechts 10 Meter. Your name will be called and once the x-ray has been taken, then come back in here immediately and we’ll talk about what needs to be done. >> Yes, good. >> Ok? Goodbye. >> Thank you, doctor. See you later. [NO_AUDIO] Radius fractures are distinguished according to various classifications. The Colles or Smith Classification, for example, is widely used. Colles applies to an extension fracture, while Smith to a flexion fracture. The AO Classification is also important as well. Distinctions are made within this between intra- and extra-articular fractures. Diese Grafik zeigt die AO-Klassifikation von distalen Unterarmfrakturen. This slide shows the AO Classification of distal forearm fractures. Type 23-A fractures are extra-articular. Within this, a 23 A1 fracture involves a fracture of the ulna with the radius remaining intact, a 23 A2 fracture is a simple impacted radius fracture and a 23 A3 fracture is a fracture with extensive debris zone and high instability. Type B fractures are sometimes accompanied by the involvement of a joint. This means that the transmission of strength is sometimes interrupted. B1 means a sagittal fracture line, B2 a coronal one with dorsal avulsion and B3 coronal with palmar avulsion. Type C injuries are entirely intra-articular with interruption of strength transmission being complete. C1 are closed intra-articular fractures, C2 are articular fractures with a metaphyseal debris zone and C3 fractures are multi-fragment fractures in broken joints. The criteria for instability are important for determining the treatment to be administered. These are, for example, an initial dislocation by more than 20° to dorsal or contraction of the base of the radius. Furthermore, a metaphyseal debris zone or dislocated intra-articular fractures are also included within this. If two to three of the criteria are present, then the injury is classified as being severely unstable and requiring surgical stabilisation. Frequent concomitant injuries are scapholunate ligament and TFCC lesions. As always, a clinical examination calls for the investigation of peripheral perfusion, motoricity and sensitivity. Imaging diagnostic investigation in conventional x-ray takes place in two planes. If any comminuted fractures are present, then the indication should be made for extensive MRI examination. >> Please come over here. Please, take a seat. >> Thank you. >> Your wrist is unfortunately broken. I’ll just show you your x-ray images. This is your hand when x-rayed from the front and here from the side. This is what is referred to as the radius and that is the ulna bone. You can now see just how much this area of the bone is fragmented. The joint block has also tipped backwards as well. If you want to do the best for your hand, I would recommend undergoing an operation. >> Therefore, no plaster cast or ... >> You will need to wear a plaster cast up to the operation; the type we refer to as a split white plaster cast. We’ll ask the nurses to do this straight afterwards. The aim after that, however, is that you should not need to wear a plaster cast any more. >> OK, but what exactly will you do during the operation? >> Well, given the amount of swelling now in place and the probability of even some more swelling occurring as this has only just happened, >> I would say that we could operate in a few days, for example on Wednesday of next week. In that case, we would like to check once again on Monday of next week that the swelling has receded and we would then conduct the discussions and obtain the signatures required as well as take a blood sample. The question as to whether non-operative or surgical treatment is indicated emerges from the answer obtained in response to the question as to how stable the injury is. A stable injury lends itself more towards rendering non-operative treatment appropriate while an unstable fracture should rather be stabilised by surgical means. Non-operative treatment foresees, after local anaesthesia has been administered in the fracture gap, repositioning by means of longitudinal traction on the fingers in a Chinese finger trap. Retention can then be undertaken in the plaster cast, which is split to begin with. This is important as the swelling caused by the injury can reach the compartment due to a plaster cast being too narrow. After approx. seven days, this can then be changed to a circular plaster cast for four to six weeks. It is important for x-ray check-ups on progress to be conducted at regular intervals so as to avoid any secondary dislocations. This slide shows the repositioning with finger-trap traction with the fingers being enclosed in a Chinese finger trap. Repositioning should only take place after local anaesthesia has been administered in the fracture gap and a check has been made with image enhancement. This slide reproduces a series of injuries which can be treated by means of non-operative treatment. A number of different procedures are available for providing surgical treatment. Kirschner wire or compression screw osteosynthesis provide minimal invasion. Complex comminuted fractures can be treated fully in a fixateur. The Gold Standard is represented by open plate osteosynthesis via a volar access site. Indications for plate osteosynthesis are Type B3 dislocated flexion fractures, unstable, dislocated metaphyseal comminuted fractures and C1 to C3 joint fractures. The Gold Standard is represented by a palmar access site and the use of fixed-angle plates with 2.0, 2.4 or 2.5 mm screws. These slides show typical fractures, together with indications with regard to plate osteosynthesis. An unstable A3 fracture can be clearly seen on the left side, a B3 fracture in the middle and intra-articular joint fractures on the right side. >> How long will I need to spend in hospital? >> That is a good question. If everything goes according to experience and without any complications, then you will only need to spend one night at most with us. >> I’ll need to make arrangements for someone to look after the dog for that period of time. >> OK, but the main thing is for you to get better and to have a functioning hand again. Rüdiger will just have to stay at home with his ‘daddy’. >> Yes. >> Perhaps I should tell you a bit more about the operation itself? You can see here a special plate is applied to this radius bone. That is precisely what we will do in your case as well. We make a skin incision approximately 4 cm long in this area, then we carry out preparations on the tendons and the nerve and past these deeper down, jiggle this bone back together again at the end, put it in position and it is then secured by means of a plate and screws. In an ideal case, this special plate will then remain there for ever. It can, however, be removed again after one year if you experience any complaints, for example any sensitivity to the weather. >> Yes. >> Yes? >> OK. >> Do you have any other questions? >> No. OK, then let's go for that the way you have described, yes. >> Good, Then I’ll call the nurse now and she can apply the plaster cast and I’ll wish you a speedy recovery. >> Yes, thank you. >> Goodbye. Follow-up treatment depends to a considerable degree on the intraoperative bone quality. The objective is always to provide early functional follow-up treatment. - Let me summarise: Radius fractures are the form of fracture most frequently suffered by human beings. The criteria for instability are important for determining the treatment to be administered. Stable fractures can be fully treated in plaster casts, while unstable fractures must be treated surgically. Many thanks for having listened so attentively. [MUSIC] [MUSIC] [MUSIC] [MUSIC] [MUSIC]
