The three major complications of fractures are infection, osteofascial syndrome, and nonunion. One is more terrible than the other, the first two are short-term complications, and the latter one is long-term complications. If there is no postoperative follow-up, the situation will already be serious by the time symptoms appear.
In the orthopedic operating room in the early morning, Zhang Fan looked at the patient's X-ray and frowned. It wasn't that the surgery was difficult, but that he couldn't feel the transparency of liver tumors.
Orthopedics is the discipline that Zhang Fan first came into contact with, and it also involves a lot of surgeries. Although he is becoming more and more skilled in surgery, there is always a lack of transparency, as if something is missing.
"What's the reason? Is it because there are too few surgeries, or is the surgery not difficult enough?" Zhang Fan's brows remained knotted, and others did not dare to disturb him.
In fact, this matter is very simple. Wherever there is oppression, there is resistance. As long as it is not suppressed, it will definitely sublimate and break through. Liver tumor surgery is not the most difficult surgery, but it is not simple either.
The risks of surgery for huge liver tumors are even greater, in this cautious and cautious manner. Zhang Fan worked hard to apply knowledge and think hard.
Suddenly, the knowledge about the liver was forcibly broken through. On the contrary, simple orthopedic surgeries become more and more proficient and become a habit, and breakthroughs are out of the question.
"Zhang Yuan, the anesthesia is over. We are all ready." Zhou Chengfu gently reminded Zhang Fan who was in a daze.
"Oh, are you ready? Let's start." Zhang Fan seemed to have just woken up, put aside his thoughts, and concentrated on starting the operation. So far, the medical community has not yet unified the definition of nonunion.
Zhang Fan believes that if the broken end of the fracture fails to heal within three months without intervention, it should be called a nonunion. Zhou XX had diabetes, and Chen Qi also wanted to make the surgical X-rays more beautiful, so he peeled off too much soft tissue.
Moreover, the patient also smoked, drank, and did not do moderate strength exercises, which eventually led to nonunion. At this time, the disconnection point at the middle end of his humerus had shrunk and a large number of granulations had formed.
The human body is so strange. If normal tissues cannot grow in normal places, abnormal tissues will grow. If it is discovered a few months later, atrophy will increase due to the loss of use of the bone.
Pseudojoints will appear in a short period of time. A normal arm only has one elbow joint. Because of the pseudojoints at the broken end, his arm becomes a three-section stick.
If the time is prolonged, it will be like an infection, and the originally normal bone mass will begin to shrink, and the final outcome can only be to shorten the arm. Then one arm became long and the other arm was short, leaving an irreversible disability on the body.
There are many ways to treat nonunions, including lengthening the steel plate. After removing the original five or six centimeter steel plate, the broken end is corrected, bone is grafted, and then a longer steel plate is put in to strengthen the stability of the fracture and allow it to recover.
The other method is intramedullary nail fixation, where the opening is directly viewed from both ends of the long bone and intramedullary nails are inserted for fixation.
Another option is external fixation. Just like building a building, a steel frame is set up to fix the fracture.
Because the broken end of Zhou XX's fracture was not shrinking very far at present, Zhang Fan planned to use an extended steel plate to fix it. Each of the three fixing methods has its own advantages. There is no best, only the most suitable.
After incision, Zhang Fan continued to insert the knife into the original incision. This kind of secondary surgery could not talk about the hierarchical structure at all. Because of the surgery, there were severe adhesions around the incision.
Zhang Fan observed the two assistants as he entered. The two of them cooperated with Zhang Fan very skillfully. After the incision was opened, black threads that had not been absorbed kept appearing, some long and some short.
Although this kind of thread can be absorbed, if you find it, you still need to remove it as much as possible. After all, the thread ends are considered foreign matter. Silk thread absorption is a joke in the medical community.
It is said that in the early years, the country's technology was poor and the silk thread materials used were not up to standard. Thirty years after a person had an appendix surgery, a black thread would still grow somewhere on the body.
When the muscle is opened, the steel plate has been wrapped by proliferated granulation tissue. What's the situation? It's like placing a steel plate on a plaster mold. After the plaster mud is pressed, it overflows. The plate attached to the bone is surrounded by this calcified granulation tissue.
"Steel nails from the inner six." Zhang Fan took a look and said to the nurse. The screw heads of orthopedic steel nails used to have plum blossom and cross heads.
Once this type of screw becomes uncomfortable with excessive force, the screw head will be cracked and it will be impossible to bite it when taking it out. In other words, there is an unwritten rule in orthopedics.
Whoever gets the steel plate gets it! With a lot of complaints from orthopedic surgeons, this kind of plum blossom and cross screws have slowly withdrawn from clinical practice. This is the origin of the orthopedic legend: there are no steel plates that cannot be installed, only steel nails that cannot be removed.
After unscrewing the steel nail, Zhang Fan directly bit the steel plate with two Alice pliers and pulled hard, and the steel plate was pulled out from the calcified granulation tissue.
The instrument nurse looked at Zhang Fan holding the Alice pliers to remove the steel plate, gritted his teeth and said nothing. If this had happened to other residents or general attendings, the nurse would have been displeased.
The surgery is under the control of the doctor, but the instruments are under the control of the nurse. And because of the violence of orthopedic surgeons, doctors in other departments are very reluctant to use the instruments used by orthopedic surgeons.
The pliers are used to clamp bones and steel plates. After clamping a few times, the instrument that looks very new becomes useless, and even a suture needle cannot be used to sew with force.
Pull off the steel plate. "Bone Knife!" Zhang Fan started to remove the calcified cartilage tissue on the bone surface as he was about to use the bone knife. The bone surface seemed to be embedded with a bony steel plate.
If the density of calcification is relatively high, a bone knife is not enough, and a hammer is needed. Just like chiseling a stone, the calcification on the bones is removed in one stroke.
This operation must be stable and there must be no accidents. Once the hand slips, the kinetic energy of the hammer coupled with the power of the doctor's arm will definitely break the patient's bones.
"Steel! Steel! Steel!" The sound of the hammer hitting the bone knife resounded in the operating room. And it still needs to be rhythmic, you can’t knock randomly, and the time interval between the last time and the next time should be about the same.
Zhang Fan knocked, and Zhou Chengfu spread his fingers to hold the incision. Due to the strong percussion, the blood, bone marrow, and fat particles in the wound were like dancing wildly with Zhang Fan's percussion. Although Zhou Chengfu had covered the wound with his hand, there were still yellow fat particles eloping out with blood.
The surgical drape was dotted with fat particles and blood soaked in the drape, which looked like sesame cakes, not black sesame seeds, but yellow sesame seeds.
"Curetape! Start taking out the bones. Don't take out too much. Bring the periosteum!" Zhang Fan said to Zhou Chengfu. The bone has shrunk, and it can't heal if you don't find a way to connect it back together.
Bone graft must be cancellous bone with periosteum. Because there are a large number of osteoprogenitor cells on the periosteum, these cells allow bones to develop and grow, and cancellous bone looks like the stopper of an old-fashioned thermos bottle after it has been dried. There are a large number of voids inside, which are rich in various growth factors, which can induce bone growth.
There are only a few places in the human skeleton that contain both periosteum and cancellous bone, and there are even fewer places that can be cut off. For example, the iliac spine is a very good bone bank.
"Okay." After Zhou Chengfu agreed, he moved Xu Xian to the pelvic position. If Zhang Fan's bone-breaking knife is considered violence, taking the bones is directly called violent.
After incising the skin and pulling away the fat and muscles, Zhou Chengfu gritted his teeth and began to remove the bones. The bone knife was placed on the iliac spine, so Zhou Chengfu wore a mask. If he didn't wear a mask, he would definitely look hideous at this time.
The hardness of the periosteum and cortical bone is very high. As Zhou Chengfu struck, the whole body of the tied patient was vibrating. It was like "Bang! Bang! Bang!" The blood spread out like flowers. This is not the most brutal treatment in orthopedics.
A piece of bone was cut off with a bone knife. It was not big, slightly shorter than Green Arrow chewing gum, and the bone was removed as thick as a matchbox.
After taking out the bones, Zhou Chengfu began to cut them into pieces with scissors. Zhang Fan was using a spatula to clean out the granulation tissue at the broken end. How could I describe it? It was like using a spoon to dig out the little remaining yogurt pot.
Use a bone knife to dig out the calcified granulation tissue, and use a curette to dig out the white granulation tissue that has not yet been calcified. These must be cleaned. If it is not cleaned thoroughly and there is still residue at the broken end, the bone will think that this place is where flesh grows, and no new bone will be produced.
"Gauze." After Zhang Fan dug it out, he started wiping it with gauze. Removal of granulation tissue must be ensured. After wiping, the broken end of the fracture is as white as a broken ivory chopstick.
"Zhang Yuan, look at it, is it enough?" Zhou Chengfu handed the bone pieces that had been cut into soybean-sized pieces to Zhang Fan.
"Yes, the estimate is good, it should be enough." Zhang Fan praised Zhou Chengfu. In the past, Lao Zhou would have scoffed at it, but now, Zhou Chengfu is so happy that his eyes are lined.
Filling requires technique. Just like after a hollow bamboo is broken, the soybeans must be filled into the middle without spilling. This is the technique.
Students who were not good at playing with building blocks when they were young will not be able to do this well. Lao Zhou probably had no building blocks to play with when he was a child, so in the end he had no choice but to write articles.
First, the bone fragments with cortical periosteum are placed as the base, and then the cancellous bone is filled on top bit by bit, and then the bone fragments with cortical bone and periosteum are filled on top.
It's not okay to make it loose, because you have to use an electric drill to open the holes to install the steel plate. If it's loose and the steel plate isn't even installed, the filled bones will collapse long ago.
What is taking advantage of every opportunity? This is taking advantage of every opportunity. After the broken ends are filled, bone fragments with cortical bone must be used to forcefully insert them into the gaps. It must be inserted with force.
Then, the missing bone is connected. Then put the steel plate. The humerus is not a very round tube. Because the steel plate was first installed, four or five holes were drilled on both sides of the broken end.
The second time the steel plate is installed, it must be kept away from these places, otherwise the bone may break when the screws are added, so the original steel plate that was only five or six centimeters long became a twenty or thirty centimeter steel plate. It is like adding a metal protective plate to support the humerus.
As the steel plate grows longer, the incision will of course extend. For example, the length of the steel plate is 30 centimeters, and the crossing is still 20 centimeters, even if it is small. If the area is covered by tissue, use a retractor to force it open.
Just like when a person opens his mouth to the maximum limit, he continues to use the metal retractor to pull it open until the innermost teeth are exposed.
After installing the steel plate, the humerus has a slight curvature and is slightly triangular. Therefore, the steel plate must find a surface that can fit better.
After the steel plate was attached, Zhang Fan started to drill holes. Although doctors from other departments make fun of orthopedics and say that a good carpenter can perform fracture surgery, this is actually a joke. A carpenter really can't do this job.
Open hole, this steel plate is a pressurized steel plate. One of the nail holes on the pressure plate is a pressure hole. There is a slope designed in the hole. This hole looks like an ordinary hole is elongated. The advantage is that it can exert pressure to bring the fractured ends closer together and promote healing. The disadvantage is that the pressure hole is the weakest part of the steel plate and is easy to break.
During the doctor's operation, it is difficult to control the intensity of the pressure. If the pressure is too high, it will cause slight bone necrosis at the broken end. If the pressure is too low, it will not have the effect of pressure. Because each patient's constitution is different, in actual work, this intensity is difficult to grasp.
With this level of effort, it won't be possible to master it in just a few years. Drilling along the pressure hole of the steel plate, Zhang Fan observed the connected bone blocks while drilling.
To be honest, for this kind of surgery, if you take a step forward, you must ensure the suitability of the original step. If there is a problem with the original step after taking a step forward, you will not be able to get off the operating table.
Zhang Fan was very respectful and cautious when drilling holes. Although he had inserted it with force himself, the human power could not compete with the vibration produced by the electric drill, so Zhang Fan was very careful.
After opening the hole, start installing the screws. This is also a technical job. Apart from anything else, the angle is very particular. The verticality of the screw must be ensured, and the contact surface with the steel plate and bone must be vertical.
How to be sure, feel! Yes, it's a very unreliable feeling. If you don't feel it, you'll just wait for the thread to slip. There is no problem at all. It depends on the strength of the screws that pressurize the steel plate. Once there is a problem with the direction of the engagement between the screw and the steel plate, the sliding wire will not be able to escape.
Put on the steel plate, start rinsing and suturing! When the suturing was about to be completed, Zhang Fan suddenly raised his head and said to Zhou Chengfu and Wang Pingshan: "Which one of you will take over this patient?"
Zhou Chengfu hesitated for a moment. Wang Pingshan glanced at Zhang Fan and said directly: "If you don't worry, leave it to me!"
"Okay!" Zhang Fan didn't say much. Zhou Chengfu next to him suddenly felt like something was moving away from him.
