Intraoperative Imaging in Distal Radius Fractures

Ladies and gentlemen, dear colleagues, I would like to extend a warm welcome to everybody at the screen today. We are talking about introvertive imaging in treatment of distal radius fractures. I would like to introduce the faculty of today's talk to you. This is my colleague Eric Mandelker. My name is John Franco. We are trauma surgeons at the bigger trauma center, Ludwigshafen in Germany. The learning objectives of this presentation are why do you need imaging and treatment of distal radius fractures? How do you perform imaging and what are the standard projections in 2D and how do you perform a 3D scan with a mobile C arm on what are the standard planes in 3D and how can you analyze the three data set? And now we come to the question, why do we need imaging if we treat a distal radius fracture typically with a volar plating we have only a. A small insight into the approach where we see the surface of the bone but we don't see our fracture reduction. And we don't see our implant placement regarding the placement of the screws next to the joint line and therefore we need imaging. Now I want to show you how to perform. The standard fuse. In 2D this means the A, the lateral and some other standard fuse. But before I show you how to perform to the imaging, I want to give you a theoretical background why we should perform it in the way I will show you later. At the distal radius we have different angles. In Germany, we call it the burlar angles. In other countries or regions you call it the so-called. Radial inclination. And in the letter of you. You have. A perma inclination. The Palma inclination is. Round about 10 degrees to the shaft axis. The radial inclination is round about 20 to 25 degrees to the shaft axis. If you look in radiological textbooks. And you check their how to perform a standard AP view, you will find you should lay down the forearm flat and the table. And we will show you now what happens if you do it in that way. Eric, please come in with the C arm. This is a standard setup in our hospital regarding the table positioning of the patient and the CM that comes from the head, because we use tables with this stance, so it's not possible to move in with the CM from the side. But if you have a table without this stamped stand, it's possible to move in this direction in general. I have the screen on the other side because the nurse is located here where the instruments. But for this video clip, we have it here to illustrate it better for you. So as I said, radiological textbook for flat on the table. This is a 30 to 30 centimeter detector. This means we have a. Large field of view. And if we want to investigate a small anatomical region like a wrist, we don't need. This large image so now we use collimation. Collimation means the field of view is getting smaller but image quality is getting better and you have less scatter radiation. This is the effect of collimation. One image please. OK, now you see we have a smaller field of view and. What Eric did, he used magnification so he enlarged the image so we can use the full screen, but we have a smaller field of view at the anatomic region. Now we will repeat the AP view. Image please. OK, I turned the image for you. Because in a standardized ways of the app view. It looks like this. The hand. Points toward the ceiling, like here and now. What can you see? You see the distillery radius. You see the ulnar? You see the lunate? The scaphoid. That recreate room and the PC form. What are the most important? Joint surface, because if we're talking about fracture treatment, as I said, we want to assess fracture reduction and implant placement and if we treat distal radius fractures, we have to place our implant next to the joint surface to. Prevent secondary dislocation after our initial reduction. This means we have to place the screws next to this joint line and this is the radiocarpal joint. This is the distal radio owner joint and we always. Should have a look at the scapholunate. Joint space 2. But this is another theme. A perfect AP view means we have a good insight into the radiocarpal joint with a minimum of overlap between the Bony structures. But now you see we have an overlap with the lunate, we have an overlap with the scaphoid, and this is the volar rim. And this is the doors and rim. And this means we don't have a good insight into the joint space of the Radiocarpal joint. Let's talk about the distal radio ulnar joint. There we used the same criteria. What do you want to have is a good insight in the joint space and what we don't have we don't want to have is the overlap of these two Bony structures or we want to minimize the overlap. And as you see here, there is no insight in the distal radio owner joint. How can we solve this problem? If you remember the Buller angles and you look at this Palma inclination here. The joint space is orientated in this direction, so if you do an image like that you will have an overlap if you want to look into the joint space. You have. To move the C arm or the object in a position that the central beam of the C arm is in the same direction like the joint space. And how can you achieve this? One possibility is. To elevate the elbow. Take the hand and press. The distal radius at the table. One image please. And then? Another movement rotate. The whole arm so that you can achieve a good insight in the distal radioulnar joint. Laser on please. Fluroscopy. OK, now what can you see? This is like the AP fuse made in radiological textbooks. This is what we call the surgical AP view. And now if you compare these both views. It is obvious that now you have much better insight into the Radiocarpal joint with a minimum of overlap between the bones. This is the volar rim, this is the dorsal rim, and you have a good insight in the distal radio owner joint much better than here. This means later after fracture reduction, implant placement. With this view, it's much easier to assess your fracture reduction implant placement. OK, let's talk about. The lateral view. Again, if you look in radiological textbooks, lateral views are made like this. The Forum lies flat on the table. X-ray. And we have the same criteria. We want. To assess the joint space and the joint lines, and if you look at this image, it is not possible to have a look into the joint space, so you cannot answer the questions you want to answer. Therefore, in the same way like we had in the AP view. Remember the bullar angle, or so-called radial inclination. And this is the joint space, so you have to bring. This direction in the same direction like the X-ray beam this means. You can leave the elbow at the table. Take. The hand or the 1st and the 5th finger and then elevate. The forearm so that the X-ray beam is in the same direction like the joint space and again you have a rotational component. I will tell you later how you can achieve a good image regarding the rotation, but first of all we will elevate it around about 20 degrees. One image please. Oh, the lucky shot. What do you see now? This is the disc radius. This is the distal owner. This is the lunate. This is discovered and you see you have a very good insight in the joint space to assess the result of your surgery. There are other criterias how you can achieve a good letter of you. I have a trick for you. The distal radius of all humans is. At the volar aspect flat. This means if you achieve. A few where the X-ray beam. Goes along this area and you will see later if there's a plate inside, it's much easier than you achieved a good letter of view. And I mean we don't do introvertive diagnostic imaging, so we have always or almost metal in place. So you will see it later. If you achieve a good letter of view of the plate, you will achieve a good letter review of the distal radius. OK, but these are not the only views that you can use at the distal radius because we have one problem. If we. Go for letter few we see the whole height of the bone but. The distal radius. Is not a box, it is not like this. And if you look from this position letter of view and you have the screws inside. And they are not penetrating here everything is good in this view the distal radius. Is shaped. Like this? This is honor. This is radio and it has a triangular shape here. So if you play screws. And you look from this direction the true letter of view. Then you cannot detect screw penetration at. This region so you need additional fuse to check this and there are two. I call it standard fuse 2 you can use. To check this it is the so-called. Those doors are radial and dorsal ulna view. What does it mean? These are tangential views. And you start with your true surgical letter of you and what you want to achieve is not only this direction you want to achieve. This direction to check this aspect of the bone and you want to check. This direction. This means if you have the distal radius in this position and the X-ray beam comes from there, you have to supinate and pronate. Your display radius and you start with. This letter of view and then you. Super Pronate and Supinate and it will be much more obvious later when we have the implant inside. So we will not perform these fuse now, but we will show you later with the implant insight on the opposite side how it works because there is much more obvious and we have two another views. These are tangential views. This is the so-called. Dorsal turn against lawyer show you my wrist, dorsal tangential few and the so-called Skyline view. With these views you can check. You will see later with metal inside. You can check the relationship between the implant and the distal radio owner joint. We can perform one of these views, the so-called skyline views. Please move over to the table. A little bit back. OK, stop. What you can see now is the outer shape of the distal radius, more or less. In an axial view this is the distal radio owner joint. And remember my drawing you see at the same shape. Rises here up to the Tuberculum misery and goes down to the radial aspect of the disgrace. And as I told you this is almost a flat region at the distal radius. And with this view you can check as I said the group placement next to the Deserado owner joint and if you have a penetration at the dorsal aspect of the distal radius. But as I said it would be much more obvious if you have an implant in place so. We will move over to the contralateral side and repeat all the standard views to make it clear for you. We want to transfer our knowledge about the standard projections in a real life situation. Real life situation at the distal radius means. We treated a complex intra articular fracture with the volar plate or synthesis. For this we used a variable angle locking plate via this volar approach and now we want to check the result of our surgery. This means implant position and fracture reduction with our 2D standard projections. We start with the AP view and we start with the method how it is made regarding to radiological textbooks, you remember this is. Forearm flat at the table perpendicular to the X-ray beam. This means. In that way, X-ray, please. Now this is our AP view. As I said, we want to check fracture reduction and implant placement. About fracture reduction, I can tell you we achieved a perfect anatomical fracture reduction. So please let us focus on implant placement because. To check the implant placement. We have to consider the same criterias. That we have then if we want to check fracture reduction, so. Remember the what is the good AP view we have to see with the minimum overlap of the volar rim and the dorsal rim the radiocarpal joint. You can see it. Properly in the in this way. One note, please don't take care about this screw in the scaphoid. This patient suffered from a scaphoid fractures many years ago. You don't want to talk about that. We focus on the distal radius. As I said, the inside then the Radiocarpal joint is OK, but. You don't have a good insight in the distal radio owner joint, so if you want to check for example only the placement of your plate, it is not really possible. And now we go through the screws. Next to the joint line because. One of the complications that can happen is that you have a intraarticular screw penetration. Or a penetration of the dorsal cortical bone. Where the tendons are and this should be avoided and we start with this illness crew and. We want to answer the question, is this screw and that this radio on a joint or in the RADIOCARPAL joint? I cannot answer this question with this view. Second screw, maybe it is in the Radiocarpal joint, but I'm not pretty sure because we learned before we need more than one projection to check this the same as with the search through and the 4th screw maybe is in the bone. Maybe it's too long. We cannot answer the question will this projection. So what we wanted to do, what we want to do now is to check implant placement. With the, as we call it surgical, a few. Please remember how it is made. You have to. Elevate the elbow. And press the distal radius. To the table regarding the bullar angle of more or less 10 decrease if you achieved an anatomical reduction. And then you have to rotate the arm so that you have a good insight into the distal radioulnar joint. One shot, please. So now. I will show you. The difference between the two views. The radiological a view and the surgical app view. We achieve now a very good insight in the distal radio owner joint. We have a little bit better insight into the radiocarpal joint than we had in the radiological a few but. We have this regarding our screws #2 and three. We have the same problem then we had. In the radiological view. You cannot really check if they are intraarticular or not. What can you do? Now. We talked about the burglar angle and if you're not able to elevate the elbow in a proper way so that you get full insight into the joint, this means if you cannot move the object that you want to investigate, then you have to move the C arm. So this means we go now to more or less 15 degrees angulation, I will say. You can see here at the screen. And then we will repeat. Our AP view OK. So this is our first app view. Surgical APU and this is our second with. More. Angulation of the C arm. Now what can we see? Now we have more information about our. Screws next to the joint line. This might be near to the decelerate on a joint, but I cannot really say if it's inside or not. The same for this crew. This crew seems to be not into the joint. Please remember this for later. And. This group seems to be good. I don't have any information about dorsal penetration and therefore I need the second standard fuel. This is the lateral. No. Please remember how a letter of view is made. If you look into a radiological textbook. Forearm in the lateral position flat to the table perpendicular to the X-ray beam. One shot, please. And now we want to talk about implant placement. You cannot see the joint line at all. How can you judge about implant position in such a few? It is not possible at all because you have a big overlap over a lot of Bony structures and as I said, no joint line, no joint space. So it's really hard to evaluate the result of your surgery in such a few well that. You have to make a surgical lateral view and as I told you, leave the elbow at the table. Take the hand at the 1st and the 5th finger. Elevate. The wrist regarding to the radial inclination, the burglar angle and then you have to rotate and as I told you the distal radius in all humans is flat at the volar side. So if you have the X-ray beam in the right projection to to this flat area or now we have a plate inside and all the plates that are available on the market are flat in this region. So if you have a really good lateral view of the plate. You always achieved a good lateral view of the wrist. OK, fluoro please. What can you see now? Now we have a perfect insight in the radial carpal joint. We see our distal radius. We see our owner. This is the lunate, this is the scaphoid and. Fracture reduction is not the problem here, that's perfect. And what can we say about all these screws? If you show me such an image, I will tell you. Looks good. All screws are in the right position directly under the joint surface to support your fracture reduction. But is this true? We don't know, so therefore we have the other standard projections to check if you have a dorsal penetration of the screws or if they are penetrating the distal radio owner joint we start. With. The so-called pronation few. This means the dorsal tangential. Few. In pronation to check if we have a screw penetration in this aspect of the distal radius, this means you have to achieve a good letter of you. This is the starting point. Please fluoro. Stop. OK, this is a letter of you. And now. We go in. Pronation position. And please have a look at the screw tips when they are penetrating the cortical bone in the dorsal aspect. We have a misplacement there fluro. Stop. So. I haven't seen any penetration of this cruise there, so. We might be sure that we don't have a penetration of the 4th and. 3rd screw because this is the dorsal radial aspect of the radius. Now the next standard view is the so-called supination view. We have to check this dorsal aspect of the distal radius. Our first and second screw. We start again with a good letter of you, floral. Stop. And now we go and supination position fluoro. And please have a look. What the screw tips are doing? And stop. What can you see here? You see a penetration of the first crew and it seems to be more or less two or three millimeters. But with this view you can really check this position. It was not possible with the AP and with the lateral, but it was possible with this dozer radial supination few. And now we want to figure out if the second screw penetrates or not. Again we start with an good letter of view. Floral. And then we supinate. We supinate. No. Stop. What you have to check if if you have the cortical bone and you rotate the distal radius the tip of the screw. Comes nearer and nearer to the cortical bone and at the highest point, if it's penetrated it's out, if it's it's moves further on and the distance it's getting longer and longer, you don't have a penetration. So with this investigation I'm pretty sure that the second screw does not penetrate the dorsal cortical bone. But we have two other standard fuses to check that. What we want to do first is the so-called dorsal tangential fuel. You remember this is made with your wrist in this position to the X-ray beam, so move the C arm to the patient please. OK, stop. One shot, please. Stop, OK? So this is so-called dorsal tangential fuel. And what you can see here, this is the distal radioulnar joint. This is the owner screw 2nd, 3rd and the 4th or the other way around, and you see a penetration of this crew here. And you see this, this, the second screw is next to the cortical bone, but you cannot see any penetration. But you have to take care. It's a tangential view and you're looking. Well, the highest point what you can see is the doors and rim of the distal radius and if the screws are not located at the rim itself, but a little bit more proximally. Then. It seems at the image that the screws and the bone, but it isn't. So you have to take care and you have to check with the other fuse does a radial fuse. And also all of you but to summarize. We think that this crew is. Not penetrating the dorsal cortical bone. And now we want to check whether with another few of the last one and there's a so-called Skyline View. And it is made you remember in this position X-ray beam in this direction to the wrist. One shot. OK, fluoro. Stop. So this is a very good skyline view. I like the sky and few more than the doors of tangential field because it is easier to achieve and image quality is better even if you have more carpal bones in the field of you. But you don't have so much Bony structures of the forearm and there the bone is more dense. So the image quality in the skyline view is better in my experience than in the dorsal tangential view. And what can you see here? Now we have much better insight into the distal radial nerve joint. And it seems that this crew is in the right position and not in the radioulnar joint. Please remember this for later when we will check this with three imaging. This crew seems to be OK. This crew is. Next to the surface, to the cortical bone. I'll show you. The contrast to the dorsal Tank Engine fuel. It's the same position then we have in the dozen technique and you see this crew is clearly penetrating the dorsal cortical bone, so it's too long. OK, now these are the six more or less standard views that you can use to check your implant position and fracture reduction. And now we want to demonstrate you how you can run a 3D scan. To check the result of your surgery. First of all you have to center the object you want to scan in the middle of the table like this. Then you have to center. The object in the field of view of the sea arm. Eric, please move over to the wrist. A little bit more and stop and we recommend always use the laser localizer to center the object so you can save radiation. But to be sure that we are on the center of the object or the center of the field of view, we control it with one shot. One shot please. What we want to see is that this radius the joint surface and the implant near the joint and you see it is displayed here and now we have to check it in. A plane that is perpendicular to the first plane so that we can be sure that it is centered during the whole orbital rotation. Because this is an isocentric arm, this means it rotates around the center. And in every angulation of the orbital rotation, the center will be in the same location. So now this is 90 degrees or perpendicular to the first few. And again we use the laser localizer. Looks good. One shot please. OK. And now you see. Again, it is centered in the field of view of the C ARM and now we have to prepare the C arm for the 3D scan. This means we go into the 3D scan mode. Have different types of. Quality of image quality I recommend to choose. High quality if we have implants in place because if you use standard or load and low dose protocol there might be a lot of artifacts especially if you have implants near a joint surface. So that you cannot really judge if the for example in this case if the screw is penetrating a joint surface or not. So I recommend always if you have implants in place. High quality this means a scan of 30 seconds. 400 images and then this is more or less semi automatic workflow this means. If you. Finished this task, the next task is getting blue and now you have to tell the system the relationship between the C ARM and the anatomic region because this is not a CT scanner where you have a table that is fixed at the gantry or the other way round. But they're they relationship with between the serum and the object is not known and later you have to process. Of the 3D scan and it's much easier for you for your orientation in a 3D space if you have a few informations in advance. Now where? What is the position of the patient and what is the position of the C arm? Now we have the patient in supine position and we are on the right side of the patient. This means the seam comes from this side and you see you finish this task, the next field opens, getting is getting blue. This is the so-called collision check. For what do we need a collision check? We have to check. That the sea arm during it, it's motorized you, you don't operate it. Manually, this means it's motorized and you have to check in advance that during the orbital rotation there is no collision between the arm or the object or the cream or some instruments or tables or the OR table itself, because. This can harm the patient if you have a collision or if you hit the table you will have movement of the object. This means you will have later a lot of artifacts. So now I activate the collision check. If you start the collision check, the system opens the brake automatically and now we performed the last decrease and now it switches. The system tells you now you're ready, you reached your end position and please or your start position, please go to the end position and the detector should be at the side of the system and the X-ray source is here. So this is what Eric performs, and now the prey closes automatically and you have 180 seconds. To start the 3D scan. To run the 3D scan you should go out of the control zone. The control zone of the system is 4 meters. If you are out of the control zone, you will not receive any scatter radiation and you have to press the left foot switch to start the three scan. So we will leave the control zone now. And I start the 3D scan by pressing the left foot switch. This is a fully motorized scan. As I said, this means during the next 30 seconds the system performs a 190 degree orbital rotation about around around the object and. It will make 400 single X-ray shots. Out of these 400 single X-rays, the computer will calculate A3 data set. Now the scan is over. And we will move over again. So now after we ran 3D scan, the system needs only a few seconds to calculate out of the 402-D images the 3D data set. And the first step you have to do is before you can analyze the 3D data set, you have to process it. Why do we have to process it? I mean this is easy as I told you the position or the orientation between the C arm and the object. Is not known, so that what we have to do now is we have two. Achieve the standard planes. In 2D we have standard fuse and in 3D we have standard planes and they are. Umm. Made in the same orientation like we made the 2D standard fuse. So I will demonstrate you how to achieve the standard planes at the distal radius. First of all I recommend. To center more or less the distal radius. In the three planes. Umm. In the centre of the field of view. Of the crosshair. Then. Move. This screen plane. This green line is the plane and it is displayed here. This red line is this plane and it is displayed here. And so on. And again. The red line this plane along the axis of the shaft. Green line along the axis of the shaft. Red line along the axis of the shaft and now. We moved to the metaphysical part of the distal radius and as I told you. Look at this axial view. The distal radius at the volar aspect is flat. As I told you. When we talked about 2D imaging, if you want to achieve a good lateral view. Letter is in 3D sagital then. Use. The orientation. Of the volar aspect of the distal radius for the orientation of your 2D. Image lateral or now your saturation view and This is why I adjust. The red plane. This one. Along the volar aspect of the distal radius. And then? I achieved. And a good rotation of the three data set. And then I go again in the middle of the object I want to investigate and now you have more or less than a view. Or coronal for you. You haven't settled with you and you have an axial view. And remember the Buller angles if I want to have. A good insight into the joint surface in the satchel to fuse I can adjust. The blue line. Along the radial inclination. Of the distal radius. Like this? And now if I go through the saturator fuse, I will be in a in the same plane in the joint space to assess fracture reduction and implant placement and these are my 3 standard planes at the distal radius. Colonel Central and axial fuel. After you achieved your standard planes, you can start to analyze your three data set. We will start in the sagittal plane. In in the part of the wrist where there's no fracture or we don't have implants inside and this is the radius and now I will. Enlarge it on this screen. I will remove. The lines so that you can have a better look at the image. And now we start in the central plane from the ulnar aspect of the wrist to radial to go through the joint space. OK, this is the distal ulnar and now we start. With the analysis. And here comes the distal radius with the plate. And now this is the step or the gap between distal ulnar and distal radius of distal radial ulnar joint. And here you see our first screw, the ulnar screw. In this few it seems to be a perfect position directly under the subcortical bone, the joint versus joint surface. We move further on to our next screw. And Please remember our 2D standard fuse. I was more or less pretty sure that this crew is not penetrating the joint surface, that this is not an intraarticular screw, but I was not 100% sure and if you see this image now it seems. To be an intra articular joint screw misplacement. But we can process this image later a little bit better, because this is a 2.7 or 2.4 millimeter screw, and if I measure this distance, it will be approximately 3.5 to 4 millimeters due to the metal artifacts around the screw. And maybe we have a chance to improve image quality there later, but now we go, we'll move on. To our next screw. This is the third one. And again. It seems to be in the joint. And the tip is penetrating here. Um. Please remember our daughter radial and dorsal ulnar screws, the dozer tangential and the skyline view, and in none of these views and not a single one. We found a penetration of this crew and the dorsal cortical bone, but it's obvious here in 3D. And now our last crew. We detected with 2D imaging of this crew is penetrating the Dawson cortical bone and we can approve this with a 3D scan in the saturated few, but. In the same way you have to analyze your the result of your surgery. In 2D this means more or less all the standard views. You have to to assess the result in all the standard planes that we have. So now we start with the second plane and this is the coronal plane and we start at the volar aspect of the distal radius and remove the lines and now we go through the three data set. Here's the plate located. See. This is the distal radial. Now join the Radiocarpal joint. These are the screws. And now if I go on, you see again. The second and third screw seems to penetrate the joint surface. And please have a look at this screw next to the distal radio owner joint. In all the other fuse there seems to be for me more space between the joint space and the screw. Here it seems to be really close to it. Maybe penetrating or not, I don't know. As I told you before, we can optimize the image quality with the so-called metal artifact reduction later and have a look if it helps us to assess whether this crew is penetrating the bone or not. OK, and now our last plane, the axial plane. So now this is the distal radioulnar joint. And in this plane. Again. Or in this claim, it seems to me really that it penetrates the bone more than in the two other planes, but we will check in some seconds. You see, this crew is good regarding the length, and now you see. This is the. Tuberculum mystery, we call it. This is where the EPL 10 goes around it. And there you see now penetrating the third screw that doesn't cortical bone. And and again this was not a result of our 2D images, we were not able to detect this. And this is what we know. Since our 2D images the radial screw is too long and what I show you want to show you with. This is a very important aspect. If you use only 2D images and if you use only the app and the lateral to check your implant position, the distal radius is not a box. It has. At the radial aspect of three angular shape, this means if you have an AP view. Or a true lateral view. You cannot detect this screw misplacement because you always have an overlap. Of the bone in this line of sight with the tip of the screw and then this direction too. So I recommend. Hardly. To use not only the standard AP and lateral views. You need more fuse in 2D or you need a 3D scan to process and analyze A3 data set. We use another application, it's called Screw scout. To analyze the position of this crew is easy if you go through all these planes, but it may be might be easier if you. Have the screw displayed in the three axis I will show you. At the example of this alnas crew. When I move the crosshair to the screw. And adjust it in all the planes along the axis. Like I do here. And there, now you have the screw adjusted in all the three planes, and. You have much more information, or for me it's better for my 3 dimensional understanding of the position of the screw in the bone. As if you go through all the planes and you have only a short part of the screw displayed in this slide. So now as I told you there is the application and look at this, it's called Screw scout and if I press the button the system starts to calculate and the application. Recognizes. All the screws and now it's ready only a few seconds recognize all the screws in the three data set. And you can see it here. I turn it. This is the plate. You see, this is the plate. These are the screws and the shaft. And. These are the four screws. In the plate 1234 and now icon with a single click at the screws or here. Back and forward. To the next crew and look what happens. Though it detected the screw in the scaffold too, but I don't. I'm not interested in this crew, so I. Press here. This is the radio screw. Next one, next one. Next one and so you can go very quickly through 3D data set and check the position of your screws in the best way in my opinion. Son, now again we come to the problem with metal artifacts. Metal artifacts are the biggest problem in introvertive imaging if you're talking about 3D imaging, because they're making the image quality worse. And now, as I told you, we have the possibility. To optimize it with metal artifact reduction. Then we have different options. I will show you the standard one, metal artifact reduction. I press standard and then. The calculation starts again and please look at the screen what happens. It takes some seconds longer than the screw detection because it's a very complex calculation. And now you see the image looks much smoother. We have less. Metal artifact. And now again I go. I start the screw scout. And I go all these screws. And maybe you recognize the. How it looks like? Without metal artifact reduction, especially if you look at this screw without metal artifact reduction. We were not sure if the screw penetrates the radio copper joint in this aspect or not, but now you can say yes, there is a subchondral cordial blown, so you can be pretty sure that this crew does not penetrate the joint in this aspect. Now we are at the end of our presentation and I want to summarize what you should take home with you. Please remember the 2D standard projections and how they are made the AP view elevate the elbow, press the wrist to the table and rotate it so that you have a good insight in the radiocarpal and radio owner joint. The letter of you. Let the elbow rest at the table. Elevate the forearm regarding the radial inclination of the distal radius or the radiocarpal joint surface. Take the 1st and the 5th finger, elevate and rotate to achieve a good lateral view. And always remember if you have a volar plate inside and you achieved a good lateral view of the plate, you achieved a good letter of view of. The distal radius. And then please use. To avoid implant misplacement or screw penetration at the dorsal cortical bone, please use the dorsal radial or supination. And the doors are ulnar or pronation few and then? You have the two tangential fuse, the so-called. Dorsal tangential view and the so-called Skyline view to check the distal radio owner joint and if the screws are located next to the dorsal rim of the distal radius to check if there is a screw penetration or not. And last but not least, if you have 3D available, 3D available, there might be situations where you can. Assess implement misplacement and it is the same with fracture reduction. I hope that we were able to demonstrate you that there are some findings that are obvious in three imaging and not so clear in 2D imaging. So this then of our presentation. Thank you very much for your attention and listening us and I hope I will see you or we will see you Eric and I in one of our next clips about intraoperative imaging. In treatment of complex intra articular fractures. Thank you.

.4 30 26 65.10 00:01:22 15 57 17 176 05-08-2021 15:33:24 Intraoperative imaging in distal radius fractures With the 2D/3D C-arm Cios Spin PD Dr. med. Jochen Franke BGU clinic, Ludwigshafen, Germany SIEMENS 3D Standard projections in 2D MENS 05 mGy 0.5 mGy ENS Healthineers with implants in place THE THE PL THE A THE P THE PC SIEMENS . Health SIEME 3D scan of dist with 2D/3D C-arm Cios Spin 3D scan of distal radius 2D Orb .- 90º Ang .- 1º hh:mm:ss Blende Serie #: Laser Bild #: Fluoro Einzel- bild Scan Drehen Live Graph Zoom Ver- Messen Spiegeln Overlay sch. Shutt. Anmerkung zurücks. Road Sub DCM Helligkeit Übersicht Referenz Szene- Vor- Näch Kontrast halten Wiederg. herige(s) ste(s) Mittlere Auto Metall- KV/mA Dosis Stopp Bildver- Target besserung Pointer Transfer Mag 1 30p/s Magnifik Bewegung UNTERSUCHUNG Rauschfilt. Pulsrate VORBEREITUNG Schließen Tastatur korrektur Scan Qualität wählen Scan Qualität Navigation Mehr Leistung: Adipös Keine Nav. Timer Hohe Qualität * 30s ※ 400 Bilder Standard Niedrige Dosis Patient/System konfigurieren Ausrichtung kV mA 15p/s Scan Q 60s ※ 400 Bilder Sc Scan Qualität wähle Na Keine Scan Quali Sca 400 Bilder can Qualität 30s ※ 400 Bilder Scan Qualität w 50s ※ 400 Bilder kVImA Scan Quall Scan Qualität wähler Navig Mehr Leistung: Ad Mehr L KVimA wäh Qualität ung: Mehr Leistung: Patientenausrichtung wählen Systemposition wählen Patientenausrichtung Systemposition Rücken- Bauch- lage Links Rechts KVImA Pati Sy on wählen Kollisionscheck Bauch C-Bogen manuell verfahren in: Startposition Kollisionscheck Sicherstellen, dass Bremse am Lenkhebel verriegelt ist Start Ende setzen Distal Radius Kollisionsprüfung: Keine C014/20 Strahlungsauslösung Extremität Den C-Bogen manuell in folgende Position fahren: Endposition 10.1 mGy 00:01:22 hh:mm:ss D-Scan starten Drücken Sie jetzt den um den 3D-Scan zu starten Verbleibende Zeit: 1360 x 1360 FL LUT 2 Edge 2.50 60.9 kV WW: 3500 WC: 1500 20.70 mA 3D-Rekonstruktion Evaluat Evaluation of the surgery results using the 3D scan PR Vorwarts HRA AL LL ILL Automatic finding of screws in the 3D volume With Screw Scout TH Alles anzeigen Screenshot Screw Scout Anmerloung und Messung Schichtdicke Helligkeit Kontrast Parallel Ranges Bildmanager Alles ausblenden Ruckgangig Extremitat Anmerkung und Messung Zuruck 0% abgeschossen RIMASYS Group LP SL: 0.313 110.9 kV 512 512 CT wW: 4095 MPR Clos Spin 5 cm 16.0cm 16.0cm 2.6/0.02 mA/mAs VRT WW: 65 WC: 628 WW: 331 WC: 3000 HR RPF RPH HLF PRH HAL WW: 552 WW: 379 WC: 1970 WC: 2263 PHR FAR FRA RHA 10.9 kV RT cessing 2.6/ 0.02 mA/mAs Metal artifact of the 2D/3D C-arm Metal artifact reduction Metall AH RF 2.6 / 0.02 mA/mAs WW: 4095 WC: 0 HAR 2.6 /0.02 mA/mAs Take-home me Take-home messages Please note that the learning material is for training purposes only. For the proper use of the software or hardware, please always use the Operator Manual or Instructions for Use (herelhafter collectively "Operator Manual") issued by Siemens Healthineers. This material is to be used as training material only and shall by no means substitute the Operator Manual. Any material used in this training will not be updated on a regular basis and does not necessarily reflect the latest version of the software and hardware available at the time of the training. The Operator Manual shall be used as your main reference, in particular for relevant safety information like warnings and cautions. Please note. Some functions shown in this material are optional and might not be part of your system. Certain products, product related claims or functionalities (hereinafter collectively "Functionality") may not (yet) be commercially available in your country. Due to regulatory requirements, the future availability of said Functionalities in any specific country is not guaranteed. Please contact your local Siemens Healthineers sales representative for the most current information. The reproduction, transmission or distribution of this training or its contents is not permitted without express written authority. Offenders will be liable for damages. All names and data of patients. parameters and configuration dependent designations are fictional and examples only. All rights, Including rights created by patent grant or registration of a utillty model or design, are reserved. Siemens Healthcare GmbH 2022 Heal