The Importance of Preliminary Sketches
By Lyudmil Simeonov, MD, PhD
The ability to configure a preliminary plan as a drawing gives the surgeon better orientation and security for the pending procedure.
It is well known that the hand is a complex sensory and motor organ. The morphology of the hand consists of intricate heterogeneous structures that are unforgiving to injury. Operative treatment of the hand requires from the surgeon an ability to manipulate & orient the injured structures in 3 dimensions. As a junior surgeon, I had difficulty accurately visualizing the damage that had occurred. At that time, diagnostic imaging was not so detailed, and in order to form a clear picture of the pathology, I made drawings. For each more complex case, I prepared drawings and schemes that I hung in the operating theatre, and this became a habit. I believe that the ability to configure a preliminary plan as a drawing gives the surgeon better orientation and security for the pending procedure. During my student years, I had the opportunity to receive non-professional training on the basics of drawing and painting, which helped me develop this skill. In this regard, I have great admiration for the work of Dr. William Littler. His professional sketches are an aesthetic addition to his huge contribution to the understanding and treatment of hand diseases.
This process of making preliminary sketches is especially useful in treatment of multifragmental, intra-articular fractures. Figures 1-4 depict an intraarticular fracture-dislocation of the radiocarpal joint. On the basis of routine X-ray projections and CT scan images, I first made drawings of the displaced fracture-dislocation (Figure 1). The next sketch depicts how the fracture should look after reduction and fixation (Figure 2). In this case example, the avulsed volar-ulnar edge required the use of fragment specific fixation. The small fragment size would not allow its fixation solely by the volar locking plate (Figures 3 and 4). I also use this technique for teaching purposes to help the hand surgery fellows to understand and learn the algorithm of diagnosis and treatment of the different fractures. I advise them to prepare drawings and sketches for upcoming cases. These drawings improve orientation to the nature of the damage, and train a surgeon’s hand– a skill that is important in surgery and microsurgery of the hand.