Post on 21-Feb-2017
EXTERNCONFERENCE
EXT. ANYAMANEE
PATIENT PROFILEผปวยเดกหญงไทย อาย 4 ป 6 เดอน ภมลำาเนาอำาเภอดานขนทด จงหวดนครราชสมาcc: ลมกระแทกพน 5 ชวโมงกอนมา รพ.PI: 5 ชวโมงกอนมารพ. ขณะวงเลนกบเพอนทโรงเรยน มการกระแทกกน แลวลม แขนขางซายกระแทกพน มอาการปวดบรเวณขอพบแขนซายมาก ขยบงอแขนไมได ขอศอกผดรปมบาดแผลถลอกเลกนอยบรเวณขอพบ คณครจงนำาสงทรพ.ดานขนทด แลวสงตวมารกษาตอทรพ.มหาราชนครราชสมา
PHYSICAL EXAMINATION• A : PATENT AIRWAY, CAN FLEX NECK, • B : RR 22/MIN, EQUAL CHEST MOVEMENT, LUNG CLEAR, CCT –
NEG• C : BP 100/60 MMHG, HR 109/MIN• D : E4V5M6, PUPILS 3 MM IN DIAMETER REACT TO LIGHT
BOTH EYES• E : DEFORMITY LEFT ELBOW, ABRASION WOUND SIZE 1*3 CM
AT LEFT ARM WITH ECCHYMOSIS SIZE 3*3 CM
PAST HISTORY NO UNDERLYING NO HISTORY OF BONE FRACTURE NO HISTORY OF OPERATION NO HISTORY OF DRUG ALLERGY NO PREMEDICATION LAST MEAL 15.30 PM
PHYSICAL EXAMINATION• HEAD: NO EXTERNAL WOUND• MAXILLOFACIAL&OROFACIAL: CAN OPEN MOUTH, NO EXTERNAL
WOUND OR CONTUSION AT FACE, NO THEETH LOSS• CERVICAL SPINE & NECK : NOT TENDER ALONG C-SPINE, CAN
FLEX NECK• CHEST : LUNGS CLEAR AND EQUAL BREATH SOUND, NO
ADVENTITIOUS SOUND, NO STEPPING AT CHEST WALL AND NOT TENDER, NO EXTERNAL WOUND AND CONTUSION AT CHEST
• ABDOMEN : SOFT, NOT DISTEND, NOT TENDER, NO EXTERNAL WOUND OR CONTUSION
• NEUROLOGICAL : ALERT, MOTOR POWER GRADE V AT RT UPPER LIMB, BOTH LOWER LIMB
PHYSICAL EXAMINATIONExtremities : left arm Deformity Ecchymosis & Abrasion
wound Swelling Tenderness & Pain on
motion Limit ROM of elbowExtremities : left hand Radial & ulnar pulse can
palpableThumb extensionThumb palmar abductionThumb adductionFinger adductionNormal sensation
DIAGNOSIS
SUPRACONDYLAR FRACTURE OF LEFT HUMERUS
EARLY TREATMENT AT ER
LONG ARM A-P SLAB PETHIDINE 19 MG IV FOR PAIN CONTROL
DEFINITIVE TREATMENTSURGERY : CLOSE PINNINGON POSTERIOR SLAB 4 WKOBSERVE COMPARTMENT SYNDROME AND NEUROVASCULAR INJURY
SUPRACODYLAR FRACTURE
DISTAL HUMERUS ANATOMY
DEFINITION FRACTURE THAT INVOLVE LOWER END OF HUMERUS USALLY INVOLVING THE THIN PORTION OF THE HUMERUS THROUGH OLECRANON FOSSA OR JUST ABOVE THE FOSSA OR METAPHYSIS
MECHANISM OF INJURY
fall on outstretched hand(Extension type)
MECHANISM OF INJURY
Fall Directly on the elbow(Flexion type)
CLASSIFICATIONGARTLAND CLASSIFICAITON
ASSOCIATED INJURIES
1.Neuraplexia•anterior interosseous nerve neurapraxia (branch of median n.)
the most common nerve palsy seen with supracondylar humerus fractures
•radial nerve palsysecond most common neurapraxia (close second)
•ulnar nerve palsyseen with flexion-type injury patterns
ASSOCIATED INJURIES2.VASCULAR INJURY 3.COMPARTMENT SYNDROME
PRESENTATION• SYMPTOMS
• PAIN• REFUSAL TO MOVE THE ELBOW
• PHYSICAL EXAM• INSPECTION
• GROSS DEFORMITY• SWELLING• BRUISING
• MOTION• LIMITED ACTIVE ELBOW MOTION
PRESENTATION: NERVE EXAM
•AIN neurapraxia •unable to flex the interphalangeal joint of his thumb and the distal interphalangeal joint of his index finger (can't make A-OK sign)
•radial nerve neurapraxia•inability to extend wrist or digits may be •present due to radial nerve injury neurapraxia
PRESENTATION VASCULAR EXAM
VASCULAR INSUFFICIENCY AT PRESENTATION IS PRESENT IN 5 -17%
DEFINED AS COLD, PALE, AND PULSELESS HAND
COMPARTMENT SYNDROME EXTEND FINGER
IMAGINGAP AND LATERAL X-RAY OF THE ELBOW
MEASUREMENT IMAGING•displacement of the anterior humeral line
•anterior humeral line should intersect the middle third of the capitellum •capitellum moves posteriorly to this reference line in extension type fracture
MEASUREMENT IMAGINGAlteration of Baumann angle
Baumann's angle is created by drawing a line parallel to the longitudinal axis of the humeral shaft and a line along the lateral condylar physis as viewed on the AP image normal is 70-75 degrees, but best judge is a comparison of the contralateral sidedeviation of more than 5 degrees indicates coronal plane deformity and should not be accepted
TREATMENTTYPE 1
LONG ARM SLAB 3 WEEKS TYPE 2
CLOSE REDUCTION THEN ON LONG ARM SLAB3-4 WEEKS (ELBOW FLEXION 60-90 DEGREE)
TYPE 3SURGERY PERCUTANEOUS PINNING ORIF WITH K-WIRE
COMPLICATIONPin migration
most common complication (~2%)Infection
occurs in 1-2.4%typically superficial and treated with oral antibiotics
Cubitus valguscaused by fracture malunioncan lead to tardy ulnar nerve palsy
Cubitus varus (gunstock deformity) caused by fracture malunion usually a cosmetic issue with little functional limitations
COMPLICATIONVASCULAR INJURY
PULSELESS HAND AFTER CLOSED REDUCTION AND PINNING (3-4%) VOLKMANN ISCHEMIC CONTRACTURE
INCREASE IN FOREARM COMPARTMENT PRESSURES AND LOSS OF RADIAL PULSE WITH ELBOW FLEXED GREATER THAN 90°POSTOPERATIVE STIFFNESS