Gou in the operating room to add some upgrades

Chapter 232 Treatment
"What? Joint reduction? What kind of joint reduction?" At one o'clock in the morning, Fang Xian received a call from Du Lixiao.

Du Lixiao is the chief physician of Huang Bohang's team.

"Teacher Fang, it's a surgical reduction of shoulder joint dislocation. A relative of mine came to the hospital around eleven o'clock. I tried it twice, but it didn't go in. Then Director Huang came and did it twice."

"I was planning to go to my aunt to talk about open reduction. But Director Huang said, I want to ask Teacher Fang again. After all, this is my cousin."

"Teacher Fang, could you please come and take a look?" Du Lixiao explained very politely.

Fang Xian looked at the time, one o'clock 47.

This was more than two hours and almost three hours, which was extremely troublesome.

"Okay, I'll come over here, but I may not be able to help." Fang Xian responded.

In any case, Du Lixiao was also traveling with him. His relatives were injured and when he came to beg for help, he still had to help those who could.

After Fang Xian put on his clothes and rushed directly into the operating room, he found that the shoulder joint was dislocated. Except for an X-ray, there was no other examination.

Now under anesthesia, the patient arrived on the operating table. The dislocated shoulder joint was still tied tightly.

Although Fang Xian said that his proficiency in manual reduction of joint dislocation was not high, his theory of joint surgery and trauma surgery was deep enough.

After watching the plain film, he said: "Brother Xiao, is this a dislocation of the shoulder joint?"

Shoulder dislocation is divided into anterior dislocation and posterior dislocation according to the position of the humeral head.

Anterior dislocation of the shoulder joint is common and is often caused by indirect violence. For example, when a fall occurs, the upper limb is abducted and externally rotated, the palm or elbow touches the ground, and an external force impacts upward along the longitudinal axis of the humerus. The humeral head passes between the subscapularis and teres major muscles. The weak part avulses the joint capsule and prolapses forward and downward, forming an anterior dislocation.

The humeral head is pushed under the coracoid process of the scapula, forming a subcoracoid dislocation. If the force is severe, the humeral head moves forward to the subclavicle, forming a subclavian dislocation.

There are many complications in inferior dislocation, and in this inferior dislocation, Fang Xian estimates that there is entanglement of soft tissue, for example, the long head of the biceps tendon is wrapped around the humeral head.

You can't reset it with ordinary reset techniques.

Du Lixiao had a cold sweat on his forehead when he heard this.

"Brother Xian, when my aunt called me at first, I didn't think so much about it."

"Can this kind of lower dislocation be dealt with now?" Du Lixiao simply asked.

Fang Xian looked inside the operating room and there was not even a medical record.

Fang Xian thought for a moment and then asked again: "Have you had a physical examination before the operation?"

"After a brief check, it turned out to be dislocated. After all, he couldn't cooperate with the physical examination." Du Lixiao replied.

So, you didn’t do an MRI or a physical examination, you just did an X-ray and then pulled the patient into the operating room?
Fang Xian was so angry that he wanted to turn around and leave immediately.

But in the end, Fang Xian came to the X-ray and read the X-ray carefully again.

X-ray shows: The humeral head goes below the clavicle and loses contact with the articular surface of the scapula.The scapula tilts posteriorly, the dorsal side descends, and the angle between the scapula and the acromion increases.Dislocation of joint surfaces.

Then use X-ray to see the residual image of the muscles, which requires a test of skill.

From the X-ray, you can see some special muscle afterimages, which need to be positioned just right.

As his eyes flickered, Fang Xian actually discovered that under the patient's humeral head, he saw the afterimage of the biceps tendon, which was now stretched into a bow shape.

Fang Xian turned around and asked, "Brother Xiao, what should I do if this patient suffers a rotator cuff injury after the reset?"

"Have you talked to your family?" Fang Xian's voice was loud.

After the shoulder joint reduction was unsuccessful, the patient was changed from brachial plexus anesthesia to general anesthesia, so Fang Xian was not afraid of the patient hearing it.

But at least Huang Bohang can hear it.

At this moment, Huang Boyang understood what Fang Xian meant: "Doctor Fang, don't worry, if you deal with the patient's symptoms, Du Lixiao will naturally communicate with the family members about all other complications. "

"Brother Xiao, have you communicated with the patient's family?" Fang Xian didn't listen to Huang Bohang's helpful explanation at all.

In the end, the surgeon wrote his name on the operation record. Even if Du Lixiao went to communicate with his family, what use would it be?
"No!~" Du Lixiao shook his head.

"Brother Xiao, please go out and tell us now. This situation needs to be explained clearly in advance."

"If there are no medical documents, there will be no problem if you do the operation. You are old cousins, but I can't. I can't handle it without the informed consent form signed by the patient's family."

"Don't blame me for being too official and procedural. I've suffered a lot." Fang Xian also said it bluntly.

If complications remain in the future, for example, a joint dislocation is treated but the rotator cuff is ruptured, and the patient says that he did not have informed consent, he will not trouble Du Lixiao, but Fang Xian.

Who should Fang Xian talk to to reason with?

Although, if everyone works together, such things and conflicts may not happen.

But that's exactly what it is. You and I are not relatives, not even colleagues. If you trick me and then make my experience of coming here to go to the countryside disappear, who should I ask to reason?
Fang Xian is an adult, and adults must have their own understanding.

Informed consent and risk disclosure are the most basic elements of medical procedures. In the absence of the other party, you should not touch the other party, no matter how senior the leader or relative is. This is what the teachers told Fang Xian when he was studying. .

Du Lixiao thought for a moment, then nodded and said, "Okay, Teacher Fang, I'll get the family members to sign."

If you don't sign, Fang Xian won't care, and you may have to cut it off.

But after signing, with Fang Xian's skills, there might still be a glimmer of hope.

It's just that Du Lixiao was a little emotional at the moment, and he went out in a hurry.

But Fang Xian didn't care whether he was in mood or not, but was patiently adjusting to this reset.

Fang Xian's manual reset technique has already reached level 3. Now, without special points, he has reached level 4 proficiency.With such proficiency, it is not difficult to deal with this subclavian shoulder dislocation.

But if he wanted to ensure that there would be no problems with the rotator cuff, Fang Xian couldn't guarantee it, because there might already be problems with the rotator cuff.

The patient was already anesthetized, and Fang Xian couldn't even do a physical examination to rule it out initially.

How could Fang Xian perform a surgical reset without the family's signature?

After Du Lixiao left, Huang Bohang smiled and said, "Dr. Fang, you must have just started working, right?"

"Director Huang, maybe what my teacher usually teaches me is too official, so I can't get used to the incomplete procedures. It's better to say the ugly things up front."

Fang Xian is not afraid of offending Du Lixiao, nor is he even afraid of offending Huang Bohang.

If you say that you ask for a signed informed consent form, that is not giving you face, then you have too much face and I can't afford it.

This is something written in medical regulations, so Huang Bohang naturally can't say anything more.Soon, Du Lixiao came in and took a signed informed consent form for the operation (surgery). It was all a template, but the name of the operation was already written on it.

Fang Xian then saw Du Lixiao's name written generously where the chief surgeon signed.

Fang Xian no longer hesitated: "Brother Xiao, Director Huang, come here and do me a favor. Help fix the clavicle position and do anti-traction."

"Okay!" Du Lixiao saw that Fang Xian was willing to take action and quickly took his position.

Fang Xian was not polite. He reached the patient's left side, picked up the patient's left upper limb with both hands at the same time, moved his right hand down to the wrist joint, and moved his left hand up to near the deltoid muscle.

After Du Lixiao's fixed position was completed, Fang Xian began to pull.

The first important point of reduction is thorough and continuous traction. Only after the patient's dislocation is completely relaxed through continuous traction can we talk about reduction.

The process of continuous traction and slow relaxation of muscle tension is quite long. Even if Fang Xian's current proficiency is level 4, it still takes a full 3 minutes.

After testing the position where the greater tubercle of the humerus could be touched with his left hand, Fang Xian's right hand twisted around in reverse, as if to remove some kind of soft tissue pull.

The humeral head naturally returns into the gap after touching the glenoid fossa.

A soft clicking sound appeared in the ears of the three people.

After doing this, Fang Xian said: "It should be fine."

As he spoke, Fang Xian started to perform a physical examination with both hands. First, he palpated the greater tubercle of the humerus to see if it was in place. Second, he palpated the subclavian fossa to see if there was still a humeral head.

The third is to recheck whether the patient's passive shoulder joint movement is restricted.

"Brother Xiao, would you like to check again? It should be fine. We can also do a C-arm fluoroscopy to confirm the reset."

"However, subclavian dislocation of the shoulder joint has almost a 90.00% chance of being complicated by rotator cuff injury. Therefore, after manual reduction, MRI must be done to rule out or confirm the diagnosis."

"If there is a rotator cuff injury, then what needs to be sutured must be sutured. What needs to be treated must be treated," Fang Xiancai explained.

If he didn't know the severity of the accompanying symptoms of shoulder joint dislocation, Fang Xian would not have dared to be so tough with Du Lixiao.

After all, what the theory brings to Fang Yun is that there is almost a 90.00% probability of injury occurring. If it is not made clear in advance, it will be difficult to explain later.

Theoretical knowledge is actually a kind of cognitive ability, which represents whether you know or not, just like whether you can make a diagnosis.

At this moment, Du Lixiao took a deep breath while walking out of the isolation room: "Teacher Fang, it's my problem. I didn't prepare well in advance."

"Actually, it is. After all, he is my cousin. He is related by relatives, and it is on my father's side."

"My aunt came here for consultation. Even if there is some accident, I can explain it clearly. Moreover, in such an emergency, what I have to think of is how to solve the problem. Rather than informing me of the risks."

If he had never done a reset himself, it would be difficult for Du Lixiao to know how deep Fang Xian's reset technique was.

It was precisely because he had done it thoroughly, which was completely different from the previous dislocation techniques, that Du Lixiao knew that Fang Xian's technique was really not something that ordinary people could possess.

Fang Xian's toughness is due to his superior skills. Therefore, the associated rotator cuff injury he mentioned again is probably the same.

Fang Xian didn't explain any more.

After C-arm fluoroscopy.

The glenoid fossa has been filled and the shoulder joint space has been aligned. This is a good joint reduction surgery.

"The passive movement is satisfactory, and the X-ray shows that the joint alignment is good, and the reduction is complete. However, rotator cuff injuries cannot be treated with manual reduction."

"Brother Xiao, can you understand what I mean?" Fang Xian informed again.

Du Lixiao nodded, and then asked: "Teacher Fang, is this lower dislocation a super troublesome kind of dislocation?"

The manual reduction was over, and all that was left to do was for the patient to wake up from the anesthesia. Only then did Du Lixiao ask.

Fang Xian then brought Du Lixiao and Huang Bohang to the reader: "Brother Xiao, look here, at this position of the humeral head under the clavicle, in addition to the shadow of the humeral tubercle, is there another indispensable line? Check the cord-like shadow?"

"This is the long head tendon of the biceps brachii, which wraps around to form the rebound force of the bowrope structure."

"Here, the soft tissue under the clavicle and coracoid process forms an obstacle."

"On one side is the restraint of rebound, and on the other side is the resistance of the fixed tissue, which is equivalent to the humeral head being stuck here. If the biceps tendon cannot be freed, manual reduction is basically impossible."

"Furthermore, the violence that can cause such biceps tendon entanglement will never result in rotator cuff injury. This is a recognition of the magnitude of the violence."

"Even in this case, whether there is a partial rupture of the long head of the biceps tendon is currently unknown."

"So, even if it is your cousin and the other family member is your aunt, it is much better to inform him in advance than to have joint pain or even inability to move the joint after manual reduction."

Fang Xian explained.

Huang Bohang and Du Lixiao, however, seemed to be listening to a book from heaven.

Blinking his eyes: "Can the residual image of the biceps tendon be seen on X-ray?"

I understand the truth. After all, he is an orthopedic doctor and has been practicing for so many years.

Even such diseases have been heard at academic exchange meetings.

But when they saw the biceps tendon wrapping around the humeral head, they were stuck. Even if Fang Yun pointed out the corresponding position, neither Huang Bohang nor Du Lixiao could see that the disabled The specific shape of the shadow has been represented.

The reason why nuclear magnetic resonance is a tool is that it is completely superior to X-ray in displaying soft tissue. This has led to the rapid development of nuclear magnetic resonance technology and its popularization in clinical practice.

Fang Xian doesn't force it, because this is the basic skill of level 5 X-ray reading skills. Maybe level 4 X-ray reading skills can see the clues, but it is not something that level 3 or 2 X-ray reading skills can force. of.

"If you want to see this clearly, you need to analyze the X-ray display levels. Level analysis is actually a manifestation of levels. In addition to looking at anatomy, level 4 radiography is actually to clarify different levels and needs to be related to anatomy. More detailed correspondence one by one..."

"For example, this is the deltoid muscle, and the thickness of the deltoid muscle..." Fang Xian patiently explained.

The patient slowly regained consciousness and was put on a forearm sling by Du Lixiao and sent out of the operating room before returning to the ward.

Fang Xian, on the other hand, was sent out of the operating room by Huang Bohanggong. When he was at the door, he waved his hand and said, "Dr. Fang, you have worked really hard today. Fortunately you are here, otherwise Du Lixiao and I might not be able to make it at three o'clock." Can sleep."

This is true. If it is turned to open reset, it cannot be solved and dealt with in half an hour, even if it is open reset.

This time, Huang Bohang once again knew that Fang Xian's skills were profound and he could heal them.

Treating difficulties, that is, solving technical problems that they cannot solve, is treating difficulties.

(End of this chapter)