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

Du Lixiao is the chief of Huang Bohang's director group.

"Teacher Fang, it is a manual reduction of shoulder dislocation. It's a relative of mine, who came to the hospital at about 11 o'clock, I did it twice, but I didn't get in, and then Director Huang also came over to do it twice. ”

"I'm going to go to my aunt to talk about incision reduction. However, Director Huang said, ask Mr. Fang again, after all, this is my cousin. ”

"Teacher Fang, can you come and have a look?" Dulishaw explained very politely.

Fang Xian looked at the time, one forty-seven.

It's been more than two hours and almost three hours, which is extremely troublesome.

"Okay, I'll come over for a while, but it doesn't necessarily help." Fang Xian responded.

Anyway, Du Lixiao is also a companion, his relatives were injured, and when he begged for help, he still had to help.

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 were no other examinations.

Now that anesthesia has been applied, the patient is on the operating table, and the lower dislocation of the shoulder joint is still stuck tightly.

Although Fang Xian said that the manual reduction of joint dislocation is not highly proficient, Fang Xian's theory of joint surgery and trauma surgery is deep enough.

After watching the plain film, he said: "Brother Xiao, is this a subshoulder dislocation?" ”

Shoulder dislocations are divided into anterior and posterior dislocations according to the location of the humeral head.

Anterior shoulder dislocation is common, often caused by indirect violence, such as abduction and external rotation of the upper limb during a fall, the palm or elbow on the ground, the external force along the longitudinal axis of the humerus upward, and the humeral head avulses the joint capsule from the weak part between the subscapularis muscle and teres major, and protrudes anteriorly and inferiorly, forming an anterior dislocation.

The humeral head is pushed under the coracoid process of the scapula, forming a subcoracoid dislocation, and if the force is high, the humeral head is then moved forward to the subclavian brace, resulting in a subclavian dislocation.

Inferior dislocation, there are many complications, and this inferior dislocation, Fang Xian estimates that there is a soft tissue entanglement inside, for example, the biceps longus tendon, which is wrapped around the humeral head.

In general, the ordinary reset technique is that you reset a fart.

Du Lixiao's brain was a little cold sweat when he heard this.

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

"Can this kind of lower dislocation be handled now?" Du Lishaw only asked.

Fang Xian took a look inside the operating room, and there was not even a medical record book.

Fang Xian thought for a moment before asking, "Have you done a physical examination before the operation?" ”

"After a brief check, the dislocation, the physical examination cannot be cooperated after all." Dulishaw returned.

So, you just didn't do an MRI, you didn't do a physical exam, you just did an X-ray, and you pulled the patient into the operating room?

Fang Xian was so angry that he wanted to turn around and leave immediately.

But after all, Fang Xian still came to the X-ray and carefully read the film again.

X-ray showed that the inferior humeral head was infraclavicular and lost contact with the articular surface of the scapula. The scapula slopes posteriorly, descends dorsally, and the scapula increases at an angle to the acromial angle. Articular surface misalignment.

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

Some special muscle remnants can be seen on X-rays, which need to be positioned just right.

With his eyes flickering, Fang Xian really found that under the patient's humeral head, he saw the remnants of the biceps tendon, which was pulled into an arch at the moment.

Fang Xian turned around and asked again: "Brother Xiao, what should I do if this patient has a rotator cuff injury after reduction?" ”

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

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

However, at least Huang Bohang should be able to hear it.

But Huang Bohang understood Fang Xian's meaning at this moment: "Doctor Fang, don't worry, if you deal with the patient's symptoms, all other complications will naturally be communicated by Du Lixiao to the family." ”

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

In the end, the chief surgeon wrote his name on the operation record, and even if Du Lixiao went to communicate with his family, what was the use of eggs?

"Nope! ~" Dulishaw shook his head.

"Brother Xiao, then you go out and talk about it now, this situation still has to be made clear in advance."

"If you don't have medical paperwork, you can operate it, there's no problem, you're an old watch, but I can't. I can't handle it without the patient's family member signing the informed consent form for the surgery. ”

"Don't blame me for being too official and programmatic, I've suffered losses." Fang Xian also said it bluntly.

If there are complications left in the future, such as joint dislocation, but the rotator cuff is ruptured, the patient will say that there is no informed consent, and he will not trouble Du Lixiao, and then come to Fang Xian for trouble.

Who is the other party looking for?

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

But that's exactly the case, you and I are not relatives, not even colleagues, you cheated me, and then let me come here to the countryside The experience is all in vain, who do I talk to?

Fang Xian is an adult, and adults have to have their own cognition.

Informed consent, risk notification, is the most basic element of medical procedures, in the absence of the other, even if the other party is a big leader relative, you don't touch it, this is when Fang Xian was studying, the teachers mentioned the face.

Du Lixiao thought for a moment before nodding and saying, "Okay, Teacher Fang, I'll go and ask the family to sign." ”

If you don't sign, you don't care, and you may have to turn and cut.

But after signing, with Fang Xian's technology, there may be a glimmer of life.

It's just that Du Lixiao is a little emotional in his heart at the moment, and he is in a hurry to go out.

But Fang Xian didn't care whether he was emotional or not, but was patiently grinding into this reset.

Fang Xian's technique reset technique has long been at level 3, and now there is no special point addition, and it has also reached level 4 proficiency. With such proficiency, it is not difficult to deal with this subclavian shoulder dislocation.

But if you want to ensure that there is no problem with the rotator cuff, Fang Xian can't guarantee it, because the rotator cuff may have a problem at present.

The patient was already anesthetized, and Fang Xian couldn't do a preliminary exclusion if he wanted to do a physical examination.

How could that Fang Xian reset the family without signing.

After Du Lixiao went out, Huang Bohang said with a smile: "Doctor Fang, it should have just been working for a short time, right?" ”

"Director Huang, maybe the things my teacher usually teaches me are too official, so I can't get used to incomplete procedures. It's better to say all the ugly things that should be said first. ”

Fang Xian was not afraid of offending Du Lixiao, and he was not even afraid of offending Huang Bohang.

If you ask for a signed informed consent form, which is considered not to give face, then your face is too big, and I can't afford it.

This is something written in the medical regulations, and Huang Bohang naturally doesn't want to say anything more.

Soon, Dulishaw came in and took a signed informed consent form for the operation (surgery), which was all templates, but the name of the operation was already written on it.

Fang Xian then saw that the chief surgeon signed it and wrote Du Lixiao's name generously.

Fang Xian no longer hesitated: "Brother Xiao, Director Huang, you come over to do a favor, help fix the clavicle position, and do anti-traction." ”

"Okay!" Du Lixiao saw that Fang Xian was willing to make a move, so he hurriedly took his position.

Fang Xian was not polite, and when he reached the left side of the patient, he 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 near the deltoid muscle.

After Du Lixiao's fixed position was done, Fang Xian began to tow.

The first meaning of reduction is thorough and continuous traction, and only after the patient's dislocation is completely relaxed through continuous traction can we talk about reduction.

The process of continuous traction, which caused the muscle tone to relax slowly, was quite long, and even if Fang Xian's current proficiency level was level 4, it still took a full three minutes to process.

After his left hand tried to feel the position of the greater tuberosity of the humerus, Fang Xian's right hand twisted it backwards, as if it had removed the traction of some kind of soft tissue.

The humeral head naturally returns to the joint socket after touching the space in the fossa.

A soft click and a muffled sound appeared in the ears of the three of them.

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

While speaking, Fang Xian began to do a physical examination with both hands, one is to palpate whether the greater tuberosity of the humerus is in place, and the other is to palpate the subclavian fossa to see if there is still a humeral head.

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

"Brother Xiao, can you come to review? It should be okay, we can also do a C-arm perspective to determine the reduction. ”

"However, there is an almost 95% chance that the subclavian dislocation of the shoulder joint will be complicated by rotator cuff injury, so after manual reduction, it is necessary to do MRI to rule out or confirm the diagnosis."

"If there is a rotator cuff injury, then the one that should be sutured should be sutured. What needs to be dealt with will be dealt with. Fang Xian explained like this.

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

After all, what the theory brought to Fang Yun was that there was almost a 95% or more chance of damage, and if it was not explained clearly in advance, it would be difficult to explain it later.

Theoretical knowledge is actually a cognitive ability, which represents what you know and what you don't know, just like whether you can be diagnosed or not.

At this moment, Du Lixiao took a deep breath while walking outside the isolation room: "Teacher Fang, it's my problem, I didn't do a good job of preparation. ”

"Actually, after all, it's my old cousin, and I'm related, and it's my father's relationship."

"My aunt came to see a doctor, and even if there was some accident, I could explain it clearly. And, in such an emergency, what I have to think about is how to solve the problem. Instead of informing about the risks. ”

If he hadn't done the reset, it would be difficult for Du Lixiao to know how deep Fang Xian's technique of repositioning was.

It is precisely because he has done it in a down-to-earth manner, which is completely different from the dislocation technique reduction he did before, that Du Lixiao knows that Fang Xian's technique is really not something that ordinary people can have.

Fang Xian's toughness is his technical awesomeness, so the accompanying rotator cuff injury he said again is estimated to be inseparable.

Fang Xian didn't explain again.

After the C-arm perspective.

The socket is full, and the shoulder space is aligned, which is a good manual reduction of the joint.

"The passive activity is satisfactory, the X-ray shows that the joint is well aligned, and the reduction is completed. However, rotator cuff injuries cannot be dealt with by 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 the kind of dislocation that is super troublesome?" ”

The manual reduction has ended, and what we have to wait for is for the patient to wake up for anesthesia, so Du Lixiao asked.

Fang Xian then brought Du Lixiao and Huang Bohang to the reader: "Brother Xiao, look here, the position of the humeral head under the clavicle, in addition to the shadow of the small tubercle of the humerus, is there a faint cord-like shadow?" ”

"This is the long-headed tendon of the biceps brachiii that winds around to form the rebound of the bow-rope structure."

"Here, the soft tissue under the clavicle and the coracoid process form a barrier."

"On the one hand, there is the containment of rebound, and on the other hand, the resistance of the fixed tissue, which is equivalent to the humeral head stuck in it, if the biceps tendon cannot be opened, manual reduction is basically impossible to reduce."

"In addition, the violence that can cause such a bicep tendon entanglement will definitely not fail to occur a rotator cuff injury, which is a recognition of the size of the violence."

"Even, in such a case, it is unknown whether there is a local rupture of the biceps longus tendon."

"So, even if it's your cousin, the other party's family member is your aunt, tell me in advance, it's better than after manual reduction, and then there will be joint pain, or even joint immobility. Much better too. ”

Fang Xian explained.

Huang Bohang and Du Lixiao are like listening to a book from heaven.

Blinked: "The residual image of this biceps tendon can also be seen from the X-ray?" ”

I understand the reason, after all, I am an orthopedic doctor and has been engaged in the profession for so many years.

Even such diseases have been heard of at academic exchange meetings.

But when he saw the biceps tendon wrapping around the humeral head, he stuck the two of them, even if Fang Yun pointed out the corresponding position, but whether it was Huang Bohang or Du Lixiao, he didn't see it, and the specific shape of the afterimage was already represented.

The reason why there is such a tool as MRI is that MRI has to be completely crushed by X-ray at the level of soft tissues, which makes MRI technology develop rapidly and become popular in clinical practice.

Fang Xian does not force it, because this is the basic skill of level 5 X-ray reading, and it may be possible to see the clues of level 4 X-ray reading, but it is not something that can be seen by level 3 or level 2 X-ray reading.

"If you want to see this clearly, it is necessary to distinguish the X-ray display level, and the level discrimination is actually a manifestation of the level, in addition to looking at the anatomy, the 4-level reading technique is actually to clarify the different levels, and it needs to be carefully corresponded to the anatomy......

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

The patient slowly woke up, was sent out of the operating room by Du Lixiao with a forearm sling, and returned to the ward first.

As for Fang Xian, he was sent out of the operating room by Huang Bohanggong, and when he was at the door, he waved his hand and said, "Doctor Fang, you have really worked hard today." Fortunately, you came, otherwise Du Lixiao and I probably wouldn't have been able to sleep at three o'clock. ”

This is the truth, if it is turned to open reset, it is not half an hour and an hour that can be solved and processed, even if it is open reset.

This time, let Huang Bohang know again that Fang Xian's skills are profound, and he can heal them.

Healing, that is, solving technical problems that they can't solve, is for curing.

(End of chapter)