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Re: WRIST FLEXION CONTRACTURE
Odessky Jacob M.D. 20 Ноябрь 2006, 03:25
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Dear Cherian. Before to begin treatment it is necessary to be convinced, that sensitivity is kept.
It▓s an ideal case for the closed correction with Ilizarov Hexapod Apparatus or Taylor Spatial Frame!!! Both of these devices have the virtual hinge and allow precision correction from position of palmar flexion. Classical Ilizarov apparatus as can be applied. The problem that Wrist joint has two axes, therefore installation of the one hinge can occur a subluxation. To avoid, it is necessary to do x-rays every 10 degrees of correction. As to the techniques shown by dear doctor Sudhir Warrier, in his interesting presentation, I▓d like to notice, that correction at the given device is not possible according to an axis of a joint since attitudes between the device and an axis of a joint vary after the beginning of correction.
The special attention should be given to function of the fingers, probably in the end you have to make operation on lengthening of flexors tendons by tendon graft.
Yours faithfully!
Уважаемый Cherian. Прежде, чем начинать лечение надо убедиться, что чувствительность сохранена
Это идеальный случай для закрытого выведения с помощию Гексаподного аппарата Илизарова или аппарата Тейлора!!! Оба эти аппарата имеют виртуальный шарнир и позволяют при правильной его установке точно вывести кисть из положения пальмарной флексии. Классический аппарат Илизарова так же может быть применён, проблема в том, что кистевой сустав не имеет одной оси, их две, поэтому при установке одного шарнира может произойти подвывих. Чтобы этого избежать, необходимо делать снимки каждые 10 градусов коррекции.
Что же касается техники, показанной уважаемым доктором Sudhir Warrier, в его интереснейшей призентации, позволю себе заметить, что коррекция при данном аппарате не возможна в соответствии с осью сустава, т.к. отношения между аппаратом и осью сустава меняются после начала коррекции.
Особое внимание надо уделять функции пальцев, возможно в конце придёться произвести операцию на сухожильях - сгибателях - удлинение с помощью сухожильного графта.
С уважением!
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Re: WRIST FLEXION CONTRACTURE
Sudhir Warrier 21 Ноябрь 2006, 02:40
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Dear Odessky Jacob,
A few points and observations:
I have no experience with the Hexapod or the Spatial frames.
I really think we try to simplify the wrist by assigning it a center of rotation (one or two)! The complex movements at the radio-carpal,
inter-carpal and carpo-metacarpal joints formed by bones of varying sizes, shapes and function and servicing dissimilarly sized and shaped fingers
cannot be replicated by placing a hinge or two in a constrained frame.
The distraction frame we use is used to linearly distract the deformities. The angular correction is achieved by dismantling the connecting
rods/distraction rods and performing a manual correction. This correction will proceed along the articular surfaces of opposing bones and will be as near-natural as possible. The distractors are re-assembled and further linear distraction is carried out. And the procedure is repeated until
complete or satisfactory correction is achieved.
Having said that, I must admit that there are many ways to skin a cat!
I must also add that Dr Cherian has not mentioned about the status of the nerves and the function of the tendons. From the looks of the clinical picture, the flap overlies the volar structures which obviously must have been involved. The first web and the MCP joints of the index and middle
fingers also seem to need attention. These can all be simultaneously corrected as the wrist with the UMEX frame by using the extended hand frame
components. I do not embark on tendon surgery until maximum correction has been achieved AND considerable passive and active mobilization/splintage is done. An assessment at this stage will tell us the possibilities and the
requirements. Tendon / nerve surgery can then be planned more meaningfully.
Sudhir Warrier
Hand and Reconstructive Orthopedic Surgeon
Laud Clinic . Lilavati . Jaslok . LH Hiranandani . Shushrusha . Sir HN
Hospitals
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