Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

I will give some simple concepts in external fixation. It won't be didactic because trauma cases are never the same. But I'll give some very simple principles in trauma. It's very important that we have the ability to think outside the box and what's called blue sky thinking. So for Mark, for me, I have absolute indications for using external fixation in the acute situation. And that is a bone injury with an associated vascular injury requiring revascularization or someone who has a floating limb. The relative indications are a patient who's very sick, who has multiple injuries or someone who has a large bony defect with a lot of bone loss. And we have to splint the limb with external fixator. So to resuscitate the soft tissues. And the last relative case that I use regularly is a pelvic fracture that has failed nonoperative management, including interventional radiology and is hemodynamically unstable. So my way of thinking about complex related surgery and external fixation is I normally ask three questions. The first one is what the second is who and the third is when. So if we look at what I want to know what are the injuries, I'm having to deal with. But more importantly, what resources do I have to deal with those injuries? Also look at the restrictions and what else is happening because there's no point starting a big operation if you've got another 10 casualties, who are going to take equal amount of time. And also lastly, what sort of surgery am I thinking of doing? The next question is who are we going to operate on? Who's going to do the surgery because it may be out outside of my skill mix? Is there a limitation of the surgeon being available? And also we've got to think of who's going to do the next stage after the acute, who's going to do the reconstruction. And then the last question is, when is this going to be the primary surgery? Is this the second stage ary, are we looking at reconstructive surgery? And it's important to realize that unlike civilian trauma, you don't want to close the wounds early. And we in the UK military when we first went to Afghanistan used the I CRC guidelines quite extensively as we learned how to deal with conflict surgery. The other thing to realize is operating on these patient's can be a bit of an emotional roller coaster. You have good days and you have bad days, but also the patient can have good days and bad days. And we know from the work from in the end of last century that there's a try model distribution to death from trauma. The 1st and 2nd stages is what you can influence with prehospital and emergency room care. But as surgeons, we can influence the third peak by making it go wrong by making the wrong decisions. This brought out the concept of the damage control orthopedics. And the important thing is to use the physiology if you've got available of identifying the patient who is unwell and they're the ones that will require the quick external fixators. All of this is difficult to apply to conflict related, but it gives a starting point for us to plan our surgical procedures. The important thing with any of these cases is the communication both from the perioperative stage and in England, when we have these cases come back from Afghanistan, we don't operate on our own. We operate together in multiple teams and it's important to have a lead surgeon who's the doer, also another surgeon who has over well overall awareness of how the patient is responding to surgery. So the important thing is all conflict cases are challenging, do not attempt them alone if possible and try and coordinate the specialties. And this is how I try and bring in the thought process when I plan with any complex trauma cases in my practice. The important thing is the last bit is because if you record what you do, you learn by getting it right. But more importantly, when you get it wrong and that's something we learned in Afghanistan when we change our practice on a regular basis, when we saw things going wrong. So one bit of advice I can give to people is don't be frightened to make mistakes. But as long as you learn from mistakes, that's the most important. So my surgical strategy is very simple. I keep it simple and short. So the trick is turn the bleeding off, I turn the tap off, clean up the dirt and cut out the dead tissue. And the other thing is to think every time you bring a patient to theater, no matter how small they have to make progress and it we used to go for, you'll get them 90% clean, 90% of the time, an early stabilization of the bones helps with the soft tissue, resuscitation and rehabilitation. And you have to think outside of the box in the UK, we'd normally use Pastor Paris open reduction, internal fixation, interim medullary fixation, external fixation or sciatic attraction in conflict. I would advise you stick to plaster, exits or skeletal and it requires the adaptability and are able to improvise with what you've got available. So the exam effects after we found could be very versatile in the right hands. It can be quite technically demanding, especially with the military wounds. And I'll explain why. In a second, there's a high complication rate. Initially, often with pin tract infections, you get delayed healing's and failure. The reason for this was a paper that came out of the Iraq war from Tillich, one where all of the fixators that were put on in the first 3 to 6 knots of the war out of 15 13 had to be revised because they cause significant problems with the limb with infection. I think that was probably related to people not being experienced in putting the frames on or the external fixators on properly. So I use a lot of excellent fix aces. So what types can we use? You have your unilateral frames, you can have your multiplane, the frames and find wire fixators and combinations using find wire fixator and uh single pins. And then after the initial stage can often end up with a patient looking like this. So having done the initial, what do you do, then I would suggest you go back to the three questions of what, who and when and the main thing is, is trying to prevent the third hump of the try model distribution of mortality. Because as surgeons, we can sometimes only make the patient worse with a good idea. And the question you can always ask is, do I need to remove the frame? Or can I think outside the box, use the frame to hold the bone to length and just apply small techniques to restore the bone and then see how they go. So this is something that we've done in Birmingham to someone who had quite significant injuries but was not stable enough to have standard NHS civilian trauma techniques. The other things people can think of using is the varying aspects of a unilateral. So this is a paper by Professor Palace A from Swansea which shows how a simple design of a very simple external fixator. By making it into a uh diamond shape, you can actually get good reduction of quite complex fractures. So the one on the left shows there fracture of a proximal tibial which was reduced with a simple unilateral frame. And then the one on the right shows a relatively simple uh femoral fracture that could be reduced anatomically with a simple frame. It's going to be a talk just outlining to very simple flats for coverage in the lower limb and these are flats that anybody can do. Okay. So first one I'm going to talk about is the gastrocnemius muscle plan. I suspect some of you have done this flat or seen this flap, but it is a very good flat for covering the knee and the upper third of the tibia. So just to run over some basics, we use the medial head most most commonly because it because it is bigger, the blood supply to the medial head comes from the cereal artery, which comes from above the knee. And this means if there is trauma to believe, trauma tube of property will artery, the gas drops flat may still be okay. Um And the artery goes on them to the underside of flat. So it's very hard to damage your artery, which makes this a very safe and reliable flat. So as you can see and see my pointer, this is the flat, the needle head, the artery coming in underneath. Okay. So is it case this is um open fracture or be up the third? So this is, you know, the bulge of the middle head and you want to make your incision over where the main bulges thing of the, the only thing if you're careful with your incision is make sure there is a hand breadth of width between where you make your incision and any anterior wounds. So this is uh the midline marked here and then the incision marked here and the gas front flag in surgery. I think we all know sometimes the finger is mightier than the scalpel and it's an operation way to use your finger a lot. So, cut through the skin down onto the muscle. And you can see your arm a muscle. And if you get your finger, you can slide on top of the muscle in the subcutaneous plane over the whole of the dust trap muscle. So here we go into sweeping forwards to the front of the muscle, sweeping back to the midline, the back of the muscle sweeping down as far as we can glenn. If you see here, have a front edge for muscle, you can slip your finger in and then this is the salacious underneath. You can see the very delicate dissection by my friend here to get the muscle completely separated from the soleus. So now all we have to do to release a muscle is cut, distal end where it is going into soleus and forming the tender tender achilles and then release it from the midline um where it joins the lateral. So here is the midline and you'll see there is nervous cyril nerve, the short Saturn spain along the midline. But this gives you a landmark, but also you should try and not damage those nerves and faint. So this is to, here is the nerve and the vein here and we want to take this part of the muscle. So we have to then divide the medial head from the lateral head. Okay. So now we have released most of the muscle from underneath the silliest, still attached um in the midline and still attached distantly. This is where we need to release it from now. So that this is the nerve and this is where we want to cut it to release that medial head. So here we are, it's been, it's been released from slayers when are finding that midline and then we're just working out where we need to cut, which is, you can see just along here is what we need to take. So splitting along there down to here will give us that medial hand just um Um Yeah. Um So now, so we come, we follow that down, we just wear the gas drop is going in to the, so let's just release it. Destiny then you can follow up at midline, releasing it from the lateral head, slowly working your way up from distal to proximate. You see, we've now released part of it in here. We just need to keep releasing along here to get the flat to come up fully. Now we're just releasing it bit by bit. So we need to get it released all the way up through the very top here. Okay. So this is our defects. Now, we need to pass it from where it is to our defect. We need to create a tunnel under the skin were flat to go through. It's nice to be, this needs to be very wide because a flat four swell and also you will find there's some fascia here which can be tight and you need to release patch, they just cut into it, score it underneath to release it. So there's no tension at all when you put the flat under the tunnel. And what you want to do is round where the wound is undermine and release for the skin here. And so then your flat can sit past where you're open factories to get a proper seals. Okay. So now we've made our tunnel. Yes, we can then bring our flats through. Okay. You see the tunnel is nice and loose, there's no pressure on the muscle. Nothing that's going to cause a problem. Okay. It's worth taking a bit of the extra tendon at the end, particularly if you keep the tissue overlying it, the tuna synovium on it because you can graft that. And as men know every, every centimeter counts and that's the same in flats. So we'll put it through, look into where it's been undermined and then we can fix it in there with either deep stitches or stitches through the skin and then an immediate skin graft on the top. Okay. This is another case. This is a case of um trauma case. There's dead skin, the open it, there's an open patella fracture. So he raised a gas drop. You see as we described very quick raised release it distantly keep part of this tendon were between our synovium on and pull it through an immediate statement. One thing say if you look on the underside of the gastro, often it is very tenderness so you can just release that tenderness part to get an extra two or three centimeters. People talk about taking it off the femur to get extra length. I have never done that. It's okay. That's the gastro. So this is good, the gastric is good and safe or you know, upper third me, you can get it above the me super patella and the next lap I'm going to talk about is for the middle third of the tibia and you can get it down to lower third and even the ankle. Okay. So, so it's a display based fashion potatoes flat. Yeah. So it's on the medial side. It relies on the blood vessels coming from the posterior tibial artery. It's, it's a quick flat, it's normally pretty safe. Um But you have to do a skin graft to turn aside. Okay. So if you look at the tibia, the sub changes border is here and then if you draw a line, 1.5 centimeters poster at this opportunity border, um that is a fasciotomy line we use and this 1.5 market is important because the perforators coming off the tibial artery come in about two centimeters post area to the substance border. That's why if you make it, it's your incision is 1.5 centimeters. These perpetrators will be in your flat. Okay. So it's simple. So these bits of skin are, are used by the perforators. So we now just let's say we have a defect here in front of the ankle. We're going to move this bit of skin on to the front of the ankle. So this incision is 1.5 centimeters from the subject border. And we'll rely for this flat on this uh perforator here at five sentences. The flat can be as wide as you want and it should be as wide as the defect. And you can take up to the midline So the way you do is cut down through your skin, through fashion on two muscle a the anterior decision first come along with the top incision and then you make the post your incision. And as you do it, you can move a flat and see how much, how far down you need to come to get flat, to turn. So it will move and cover your defense. So flat returns and cover the tip I would say is always make when you are planning, you need to measure this point to uh this point to this point. Okay. And make sure you have enough left and always give yourself another one or two centimeters. Then we skin graft the demonstrate. Okay. So I'll just give you a case. This is no contraction, okay. So we've marked uh border, come back 1.5 centimeters marked are flat checked. Our distance from here to here is enough. You have enough limp. We measure with a swab just from here to here and then put the swab there and take it back. And then you can see if you have enough limp and we just cut down, release and cut down the top part and come along here and release the top end men start releasing coming down the poster of border until the flat turns enough to sit and cover your deeper. Okay. Must turn it in and that's it finished with skin graft on the tens you can get it to go further down. But, you know, as you can see, it's not the prettiest, but you can get it to cover lower, lower third and even down to ankle. Okay. Sometimes if you sound the flap, you're not, you don't think the flap looks good. You can put it back and leave it for maybe five days and then try again. This is called delaying and it allows the blood supply to adjust. And the only thing to say when you can't do this flat is if there's damage to the skin where you want to take flat from, and you think the perforators have been damaged, okay. Uh You know, with Raviv. But basically, the only other thing I'm going to say is if you can put muscle over fractures, that's a great idea. It doesn't matter what muscle it is. So this is a fragmentation injury with open fracture. Um What we can do, we can move tibialis anterior muscle over to cover it and they granulated from skin graft on and that solves the problem. And here's another one, this is using hemisphere layers, which has been injured to cover an open fracture just releasing half of the. Um So that's, that's holds less releasing half men skin graft it. So I know um a lot of HVAC going on open fractures followed by skin grafting that can also be successful. So, you know, this is a patient who in fact, but United and skin graft ID, that is okay. And there's another one where we got back and it's been rough. But I would suggest that, you know, if you can get coverage, it's better, it's quicker for the patient risk infection is lower. Um It allows more flexibility for feet. Surgeon for fixation cover open fractures. Um So gastric, our preferred, the medial fashion is flat, is good for middle third. You may be able to get down a bit lower and it can cover bone with muscle. That's a good point. Um But as surgeons, we know that we need to think about other things. So Mike Tyson said it's great on the plan. Everyone has a plan until they get punched in the face. We need to think about what your ultimate plan will be okay. So flat doesn't work that things don't work.