Category Archives for "Trauma"

Imagine having closed fracture cases of the upper limb in the ward waiting to be operated on. When you have to share emergency theatre space with other specialities, those life-threatening cases eg. laparotomy, caesarean section cases will be done first. The last on the list will be orthopedic cases. Even then, open fractures will be done first, followed by closed fractures of the lower limb as these patients will be either bed or wheelchair bound without the surgery.

Where does this leave our upper limb patients?

Usually, these patients will only be listed after a week or sometimes more than that because of not enough general / regional anaesthesia time. Unfortunately, this is the typical setting in our country and I believe similar in other 3rd world countries. So, this is the story how Walant transformed my practice.

It all started in 2015 in Seattle when I first heard about Walant. Dr Lalonde gave an inspiring speech on his excellent results in performing all sorts of soft tissues and bony procedures in the hand under WALANT. Videos of his patient's satisfaction does wonders to convince me that WALANT is the way forward. This inspired me to start doing Walant surgery in my practice back home in Malaysia.

With Dr Lalonde and Prof Shalimar at ASSH meeting in Seattle (2015)

I started doing minor cases such as trigger finger and carpal tunnel release under WALANT. My patients gave good feedback and would recommend other people to go for WALANT whenever possible. This motivated me even more and I started doing tendon injuries and tendon transfers under WALANT. Again, patients were very satisfied as they can start protective movement of their joints early as I was confident with my tendon anastomosis as they were mobilizing it intraoperatively under WALANT.

So where do we go from here?

In my hospital, closed upper limb fractures were deemed as having lower priority as compared to closed lower limb fractures such as femur or tibia fractures. This leads to long waiting time for surgery as we have limited operating time for cases needing general or regional anaesthesia.

This lead me to think, is it possible to do fixation of radius or ulna fractures under WALANT. Dr Lalonde has demonstrated successfully that fracture fixation of the hand is possible. Fixation of wrist fractures has been done and published so why not fractures proximal to the wrist?

So I went away and did my own research regarding bone pain. Early studies noted that direct mechanical stimulation of the periosteum produced pain in human subjects (Inman and Saunders, 1944). This pain is often described as sharp and well-localized and occurs for example in fractures (Santy and MacKintosh, 2001). In addition, patients often perceive bone pain in in pathologies confined to the bone marrow that have no obvious periosteal involvement (eg. Intra-osseous engorgement syndrome) (Lemperg and Arnoldi, 1978; Arnoldi, 1990). In these cases, the pain is often described exclusively as dull and diffuse and difficult to localize. Thus, it appears that...

...both the periosteum and the marrow cavity of bones must be innervated by primary afferent neurons capable of transducing and transmitting nociceptive information.

Armed with these knowledge, I was quite sure that WALANT will work if I inject it subperiosteally. It will go through the perforating Volkmann's canal to give effect to the bone marrow. I started doing WALANT for simple fracture eg. Nightstick fracture (isolated distal 3rd ulna fracture) as the ulna is very superficial. Patient's pain score was 0.

We all do early protected movement after flexor tendon repair. Why? It avoids the inevitable stiff, useless finger; that is why.

How many stiff useless fingers have come out of finger fractures that are K-wired?

​Many. I certainly created more stiff fingers before I started early protected movement after K wiring my finger fractures.

How we do early protected movement for WALANT K-wired finger fractures: Reduce the finger fracture with K-wires with WALANT.

Look at the fracture and the K-wires move with a low power fluroroscope. Assess the stability of your K-wire fixation, and the ease of movement. If the fracture is moving too much, add another K-wire.

The goal is functionally stable fixation, as in mandible fracture treatment. You only need enough stability that the fracture will heal in a good position of function.

- During the surgery, educate the patient about immobilization and elevation for 3-5 days till you see him again in clinic with your therapist, or till the patient sees your therapist. Teach the patient that his hand is on strike above the heart until he sees the hand therapist. You do NOT want immediate movement in the first 3 days after surgery. Immediate movement encourages internal bleeding around the fracture, which will lead to callus and tendon trapping with more scar and more stiffness. Let the internal bleeding stop. Let the swelling come down. Let the work of flexion decrease. Let the friction decrease. Let the fracture get just a little sticky. Remember that collagen formation does not start till day 3 after wounding.

This will be pain-guided movement and pain-guided healing. Explain to the patient that we did not spend 2 billion years evolving pain because it is bad for us! For patient Sally, I tell her:

"Your pain is your body's only way to say to you: "Sally, would you stop that? I'm trying to heal in here and you are messing it up! Stop it! You need to listen to that little helpful voice in your head (the pain) to avoid taking your fracture apart and getting infection from the pins I just put into your finger. You can't hear your body talking to you if you have Advil or Tylenol in your ears!"

- By 3-5 days, in cooperative patients who are now off of all pain killers, your therapist begins pain-guided early protective movement just like in flexor tendon repair. The patient cannot do what hurts to avoid losing the reduction and to avoid K-wire infection. They only need to make up to half a fist at most; just enough to keep the tendons and joints around the fracture gliding so they don't get stuck. No more than 45 degrees of movement at MP, PIP, or DIP is required. The patient comes out of the immobilizing whole hand splint to do this protected movement several times per day, depending on the pain. They can stabilize the fracture with the fingers of his other hand if this decreases the pain. They do not put their hand below the level of his heart until it no longer hurts to do it.

This clinical healing sign is far more useful than Xray healing in finger fractures. Xray healing is useless in finger fractures. Anyone who has done finger malunion surgery has seen non-healed Xrays with very healed fractures. We remove K-wires between 2-4 weeks in most patients in whom the blood supply to the bones is good (closed reduction and K-wire fixation). If the periosteum is stripped with open reduction or open degloving injuries such as wood splitters or table saws, the K-wires will need to stay in longer because it takes longer to heal the bone.