EXTERN CASE CONFERENCE

25 Jan 2017By Siravich Thamthitiwat

History Taking เดกชาย อาย 13 ป

เหตเกด 21/1/2017 เวลา 16.30 น. ถง ER เมอ 21.40 น.

Chief Complaint: 5 เจบขอมอซาย ชวโมงกอนมาโรงพยาบาล

History TakingPresent Illness

: 5 ชวโมง กอนมาโรงพยาบาล ผปวยใหประวตวาขณะกำาลงเกดขนบนไดสามเหลยม สงประมาณ 50 ซม. ผปวยเสยหลกลม ใชแขนและขอมอซายกระแทกลงกบพน มอาการปวดบรเวณทขอมอซาย ไมสามารถกระดกขอมอได ปฏเสธประวตศรษะกระแทกพน ไมมอาการหมดสต ไปทโรงพยาบาลชมชน จากนนจงสงตวมาเพอรกษาตอทโรงพยาบาล

PE : Primary Survey A : Able to tell name and event,

spontaneous neck movement B : Equal breath sound, CCT –ve, RR :

16/min C : No bleeding at long bone, pelvis,

abdomen, external, Vital sign; BP: 148/78 mmHg, P77 bpm

D : E4V5M6, pupil 3 mm RTLBE E : No tenderness along spine, able to stand

Secondary Survey S : Tenderness at Lt. wrist, no

ecchymosis A : Denied drug or food allergy M : Denied any current medication P : No known underlying disease L : Last per oral 12.00 E : Fall from small ladder (0.5

meter)

Secondary Survey Head and face : no wound at

scalp and face CVS : normal S1 S2, no murmur Lung : normal breath sound, no

adventitious sound Abdomen : soft, not tender CNS : grossly intact

Secondary Survey Ext. (Lt forearm) : no deformities,

marked swelling, marked tenderness at both medial and lateral aspect of wrist, limit ROM due to pain, able to flex and extend all digits and unable supinate pronation.No external woundNeurovascular : Radial and ulnar pulse 2+Motor : Can’t flexed wrist, able to flexed all phalanges Sensory : Intact

Investigation Lt. wrist AP, lateral

Plain film Lt. wrist AP View

Thurston-Holland’s sign

Plain film Lt. wrist lateral view

Diagnosis Closed fracture of distal radius and

distal ulnar with growth plate injury

Management Pain Control

Pethidine 25 mg IV Closed reduction with long arm AP slabAdvice about slab care, complicationFollow-up on 1/2/2560 with filming HM

○ Paracetamol (500) 1 tab oral prn for pain q 4-6

Plain film Lt. wrist AP after reduction and slab insertion

Plain film Lt. wrist lateral after reduction and slab insertion

Growth plate injury

What is growth plate? Growth plates are found in the

long bones of the body Located one at each end

between the metaphysis and the epiphysis.

When a child is fully grown, the growth plates harden into solid bone.

If left untreated, may lead to unequal or crooked limb.

Growth plate fracture; cause Usually happen with sport

training/activity or fall from height

Twice as often in boys as in girls.

The incidence of growth plate fractures peaks in adolescence.

Clinical Manifestation Visible deformity of the limb An inability to move or put

pressure on the limb Swelling, warmth, and

tenderness

Classification Salter-Harris classification

ClassificationType I Fractures Separating of bone end from the

bone shaft and completely disrupting the growth plate.

Type II Fractures Break through part of the bone at

the growth plate and crack through the bone shaft.

Most common type.

ClassificationType III Fractures Cross through a portion of the growth plate

and through a piece of the bone end. Type IV Fractures These fractures break through the bone

shaft, the growth plate, and the end of the bone.

Type V Fractures Occur due to a crushing injury to the

growth plate from a compression force.

Mnemonic

Other classification

Management Classification determine

managementNon-operativeOperative

Non-operative Salter-Harris type I and II can be treat

with conservative treatmentReduction and immobilization with

splint/slab Children Follow-up every week and splint up to

3-4 weeks

Short arm slab Consider if no distal ulnar fracture seen

Long arm slab

Operative Displacement of more than 2 mm from

distal end to proximal end Salter Harris type III, IV with more than 1

mm displacement Acute carpal tunnel syndrome Associated with ipsilateral elbow fracture

Complication Growth arrest

Complete arrest leads to length discrepancy Partial arrest leads to angulation

Partial arrest of growth plate

Angulation

Complication: treatmentBar resection with interposition indications

< 50% physeal involvement

> 2 years or 2cm growth remaining

Bar resection with interposition

Complication: treatmentIpsilateral completion of arrest indications

> 50% physeal involvementcan combine with contralateral epiphysiodesis and/or ipsilateral lengthening

35

Thank you for your attention