Discusión entre pares / m pt 30 y old

Mohamed Ibrahim Elbaqary‎Orthopaedic consultation room - Present your case here

Ayer a las 15:44 · 

m pt 30 y old
شغال في التطريز مصنع ملابس
history of trauma 10 y ago
come with mild pain and limitation ROM
plz for diagnosis and ttt

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  Mohamed Ibrahim Elbaqary prof Akram Azzam, prof Mahmoud El-rosasy, drMohamed Abdel-AAl, dr Amr Azzam, all our pro and collages

  Ayer a las 15:51 · Me gusta · 1
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  Metwally Shaheen ORIF using Herbet s screw + iliac bone graft

  Ayer a las 16:01 · Me gusta · 1
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  معتز فرعون Non-united # scaphoid with advanced scapholunate collapse for proximal row carpectomy or wrist arthrodesis we should do MRI 1ST TO clarify if the proximal fragment is still vascular or not .IT IS atrophic non union for me it will not unite + oa of the scapho-lunate articulation

  Ayer a las 16:13 · Me gusta · 1
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  Mahmoud El-rosasy ask the expert of hand surgery Prof. Muhammad A Quolquela

  Ayer a las 16:13 · Me gusta · 2
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  أشرف عبدالعزيز Volar App iliac bone graft & herbert screw

  Ayer a las 16:13 · Me gusta · 1
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  Omar El Tabbakh Non united fracture scaphoid , needs reduction and fixation with Herbert screw and iliac bone grafting

  Ayer a las 16:14 · Me gusta · 1
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  Mohamed Ibrahim Elbaqary sur sir prof Mahmoud El-rosasy we need comment of prof Muhammad A Quolquela he is the expert

  Ayer a las 16:20 · Me gusta · 1
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  Metwally Shaheen No SLAC......young patient and manual worker you have to give him the chance. ..ORIF + iliac bone grafting

  Ayer a las 16:21 · Me gusta · 2
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  Ahmed Nada Old non.united scaphiod wz radio.scaphiod arthritis SLAC ..prox pole excision with 4corner fusion

  Ayer a las 16:21 · Me gusta · 1
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  Akram Azzam I will do MRI first.For reduction int.fix.and bone graft.Give him the chance,he is still young.If failed we can think about other procedures.

  Ayer a las 16:25 · Me gusta · 4
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  Muhammad A Quolquela Good evening every one. I am flattered to be invited ..... I think this this a long standing scaphoid non union from the evident resorption at teh farcture sie from the discrepancy in size of the two fragments denoting rotation or collapse. Also on close examination of one of the PA views we can see early osteoarthritis of the radiocarpal joint depicted from slight blunting or pointing of the radial styloid

  Ayer a las 16:26 · Me gusta · 5
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  Mohamed Ibrahim Elbaqary dear sir prof Akram Azzam MRI uploaded sir

  Ayer a las 16:28 · Me gusta
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  Mahmoud El-rosasy Dr. Muhammad A Quolquela, based on your observations would you expect good outcome of a procedure saving the scaphoid or we should think of a salvage procedure e.g. four-corner fusion

  Ayer a las 16:29 · Me gusta · 1
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  Muhammad A Quolquela You can scientifically go with ORIF and bone graft as the arthritis is early and mild but there is a hihgh risk of union failure and continued symptoms so I prefer to do either proximal row caroectomy is easier with easy postoperative rehab just 2 weeks immobilization followed by early movements

  Ayer a las 16:29 · Me gusta · 5
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  Amr Azzam There are the following findings is the x-ray:
  1-resorption at the fracture ends
  2- Volar flexion of the scaphoid 
  3- loss of the normal scaphoid hight(collapse )
  4- lateral pillar arthritis of the wrist
  Clinically limited wrist dorsal &volar flex.
  So the salvage operation is preferred 
  NB. y do an x-ray to the contra lateral (normal) side to clarify mor the x-ray findings

  Ayer a las 16:32 · Me gusta · 3
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  Muhammad A Quolquela I strongly recommend against PROXIMAL POLE excision as it is like making an iatrogenic sacpholunate dissciation even if the proxiaml pole is tiny ans very small it is very important as the scapholunate ligament is attached to it the same like tibial tuberosity gets its importance from the fact taht quadriceps tendon is attached to it although it is very small

  Ayer a las 16:32 · Me gusta · 3
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  Prof. Mo. Al-Agouz ORIF with bone grafting & radial styloidectomy has a minimal role here,
  There is Arthritis at Scapho-radial & scapho-lunate joints, He will gain no benefit from such operations.
  Leave him until marked limitation & pain Exisit then Do scaphoid excision & 4 corner fusion ( this is a Salvage operation)

  Ayer a las 16:34 · Me gusta · 3
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  Mohamed Ibrahim Elbaqary dear sir prof Muhammad A Quolquela what is the deference between proximal row caroectomy and four-corner fusion regarding technique, ROM and hand grip

  Ayer a las 16:35 · Me gusta
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  Muhammad A Quolquela I would go wit excision of the whole scaphoid and doing four corner fusion i.e fusing lunate hamate capitate and triquetrum it maintains carpal height so no weakness of grip which is teh main drawback or proximal row carpectomy although some auth0rs stated that the strength will be regained with time as teh tendons get adapted to the new carpal height

  Ayer a las 16:35 · Me gusta · 3
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  Amr Azzam I am with ex hosting the patient complaint before the surgical salvage four corner fusion & scaphoid excision .

  Ayer a las 16:40 · Me gusta · 2
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  Ekramy Talat Asses the length of the other sound scaphoid (other hand) and compare to fractured scaphoid length to know the size of graft you need.then through volar approach use tricortical iliac bone graft and fix with two parallel k.wires after refreshing fracture site and removal of sclerotic margins. Then below elbow cast for 12 weeks followed by physiotherapy.

  Ayer a las 16:43 · Me gusta · 1
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  Muhammad A Quolquela dear dr albakry PRC is easier technically , range of motion is better in four corner fusion because the joint upon which the wrist now moves is congruent and natural and sheroidal so it is not prone to arthritis I am talking about the radiolunate joint but in PRC the joint upon which the wrist is moving is incongruent as it is teh capitoluante joint which is very susceptible to arthritis although the patient even then does not ahve much symptoms as teh carpal height is reduced so there is no much stress across this incongruent joint. Finally of course hand grip is better after four corner fusion not PRC

  Ayer a las 16:43 · Me gusta · 3
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  Muhammad A Quolquela of course four corner fusion is a fianl operation and done only if the patient has enough symptoms so I would prefer to postpone this kind of surgery untill as they say make the patient cry for surgery so he will appreciate the results

  Ayer a las 16:46 · Me gusta · 6
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  Mohamed Ibrahim Elbaqary dear sir prof Muhammad A Quolquela about wrist motion at which joints it happens ( flection, extension, radial and ulner deviation)

  Ayer a las 16:49 · Me gusta · 1
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  Muhammad A Quolquela the wrist is actually two joints the radiocarpal and the midcarpal . the former is teh principal and contributes to most of all wrist movements while the midcarpal has a lower contribution that is why now there is more preference to four corner fusion in which we fuse the midcarpal j. than toatl wrist fusion in which we fuse the principal radiocarpal j, . the midcarpal j. contributes mor to radioulane movements than ti palmar dorsiflexion

  Ayer a las 16:55 · Me gusta · 4
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  Mohamed Ibrahim Elbaqary
  

  استاذنا الدكتور Professor-Abdelsalam Eid منتظرين رجوعك بالسلامه يا باشا

  Ayer a las 17:01 · Me gusta · 1
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  Muhammad A Quolquela to reduce the complexity of four corner fusion we use screws better than K wires to allow early mobilization. Also they foound that we do not need to fuse all the four joints they found that the most imporatnt one is the capitoluante one as it lies transversely across the line of load of the wrist so they now fuse this joint alone with one or two screw even without bone graft as this joint is wide provided you do good removal of the articular cartlage covering both the head of the capiatate and the distal concave surface of the luante

  Ayer a las 17:02 · Editado · Me gusta · 4
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  Ahmed Rezk Elgammal No role for 4 corner fusion in this case who complains of mild pain! It is salvage procedure when symptoms are bad enough. The second point about that radio carpal movement is more important than mid carpal joint can be discussed, many authors mention that the dart throw motion which occurs mainly through mid carpal joint in the most important functional wrist motion. 4 corner fusion can be done with Herbert screw, k wires or plates, and no big difference between results. I think k wires are more simple! I would recommend CT scan followed by reconstruction if the scaphoid plus wrist dennervation

  Ayer a las 17:08 · Me gusta · 2
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  Muhammad A Quolquela Dr Elgammal, although both radiocarpal and midcarpa joints are synovial joints they are different regarding how constrained they are it is like the difference between the shoulder for example and the hip. On close examiantion the radiocarpal j, is similar to the shoulder as it it has a large head represented by the proximal row distally and a shallow concave surface proximally formed by the distal radius and the goint is represented by a single curve concave distally so it has a free and wide range of movements in all directions. if you look closely at the mid carpal jpont it is a complex S shaped curve actually two curves in the frontal view lateral and medial the lateral one is short and convex distally formed by the distal pole of the dacphoid proximally and the trapezium and trapezoid distally. The medial curve is larger and concave sitally formed proxiamlly by the lunate and triquetrum and distally the capitate and hamate so it is evident that such a complex joint shoould have less range of motion than the simpler radiocarpal one . it contributes more to radioulnar movements and more to ulnar deviation through the larger medial curve.

  Ayer a las 17:26 · Me gusta · 3
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  Muhammad A Quolquela Dr Elgammal Also there are recorded complication with the use of spider plate like extensor ruptur or irritation, impmant failre and non union. K wires need prolonged immobilization because fixation is not rigid enough with consequent stiffness. So the ideal wiould be the use of headless screws as they impart compression with higher healing rate and alloe early mobilization to avoid stiffness

  Ayer a las 17:30 · Me gusta · 2
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  Professor-Abdelsalam Eid
  

  ماذا أقول بعد كل ما قيل

  hace 19 horas · Me gusta · 2
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  Professor-Abdelsalam Eid I would go for graft and k wire fixation. Keeping 4 corner as a salvage operation if this fails.

  hace 19 horas · Me gusta · 1
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  Ahmed Rezk Elgammal Dear dr, quolquela, thanks for the nice description, I meant the functional range of motion which is called dart throwing motion, that occurs mainly in the mid carpal joint , the functional range is different from the amount of motion, functional rang...Ver más

  hace 18 horas · Me gusta · 2
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  D Mohamed Refat i think we are treeting acase of radiocarpal arthritis as acop of long standing un united scaph. so forget scaph. attack the wrist either by prc <fusion<4corner fusion according the patient job

  hace 12 horas · Me gusta · 2
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  Weam Mousa The radio carpal joint is not bad both regarding ROM and radio graphically. What about implant
  

  
  

  

  hace 12 horas · Me gusta