case teleconference

1. Orthopedic
case teleconference
Ext. Patchara Pornsopanakorn Maharat Nakhonratchasima Hospital

2. @ER
ผู้ป่วยชายไทยอายุ 42 ปี อาชีพรับจ้าง ภูมิลาเนา จ.นครราชสีมา
Chief complaint : เจ็บไหล่ซ้าย 1 ชั่วโมง PTA

3. @ER
ผู้ป่วยชายไทยอายุ 42 ปี อาชีพรับจ้าง ภูมิลาเนา จ.นครราชสีมา
Chief complaint : เจ็บไหล่ซ้าย 1 ชั่วโมง PTA
Present illness : 1 hr. PTA
ขณะยกกระเบื้องส่งให้เพื่อนขึ้นกระบะ ได้ยินเสียงกึกบริเวณไหล่ หลังจาก
นั้นรู้สึกเจ็บไหล่ซ้าย ยกขึ้นไม่ไหว ไม่มีปวดบริเวณอื่นๆ ไม่มีล้มหัวกระแทก ไม่เคย
มีประวัติไหล่หลุดมาก่อน ปฏิเสธประวัติดื่มสุรา

4. PRIMARY SURVEY
 A : can speak, C-spine not tender
 B : equal breat sound, CCT negative
 C : BP 118/59 mmHg, PR 72 /min
 D : E4V5M6, pupil 2 mm RTLBE
 E : deformity at Lt. shoulder, tender,
mild swelling, no external wound

5. SECONDARY SURVEY
• Allergy : no food/drug allergy
• Medication : none
• Past history : no U/D
• Last meal : 4 hrPTA
• Event : as in present illness

6. Physical examination
Ref : http://www.rhpphysiotherapy.com.au/blog/1343/

7. Physical examination
• GA : A Thai male, fully alert, well co-operative
• V/S : BT 37.1 C, BP 118/59 mmHg, PR 72 /min, RR 18
/min
• HEENT : no pale conjunctivae, anicteric sclerae
• Skin : no external wound seen
• Heart : normal S1 S2, no murmur
• Lung : clear, equal breath sound both lungs
• Abdomen : soft, not tender, normoactive bowel sound

8. Physical examination
• Extremities : deformity and tenderness at left
shoulder, arm in abduction and external rotation
while resting, humeral head can palpate at
anterior of shoulder, limit ROM due to pain, ruler
sign +, duga sign -, cap. Refill 2s
• Neuro : motor power gr. V all extremities,
sensory intact, reflex 2+ all

9. Film

10. Diagnosis
Anterior shoulder dislocation
with greater tuberosity fracture

11. Shoulder Dislocations
• Definition : head of humerus loses its articulation with
the glenoid cavity of the scapula
• Classification
 Anterior dislocation (98 percents)
 Posterior dislocation (2 percents)
 Inferior dislocation (very rare)

12. Anterior shoulder dislocation
• Mechanism : anteriorly directed force on the arm
when the shoulder is abducted , extension and
externally rotated

13. Risk factors
• Young age
• Male sex
• Competitive level of sports
• Contact sports
• Excessive caosular laxity
• Large gleno-humeral bone defects

14. dwyane wade 25 yr.

15. Anatomy

16. Anatomy

19. Anterior shoulder dislocation
• Associated injuries
 labral & cartilage injuries
Ex. Bankart lesion – associated with a high recurrence rate of dislocation
 fractures & bone defects
Ex. Hill Sachs defect (a divot or flattening of humeral head)
Greater/lessor tuberosity fracture
 nerve injuries : Axillary nerve injury (transient neurapraxia)
 rotator cuff tears : depend on ages

20. Sign and symptoms
• Pain
• Resting position : slightly abduction and external rotation
• May be palpate head of humerus at deltopectoral groove
• Hamilton ruler sign
• Duga’s sign
• Axillary nerve injuries
• Deltoid weakness

21. Sign and symptoms
Hamilton ruler sign
• Flatted acromion process to lateral
epicondyle
Duga’s sign

22. Film
• AP
• Transcapular Y view

23. Management
• Early reduction (control pain / under GA)
• Interlocking sling
• Film after reduction
• Rehabilitation

24. Reduction
• Hippocrates
• Stimson
• Milch

25. Reduction
• Zero position
 Abduction 165 degree, forward flexion 45 degree, medial epicondyle on anterior
 Traction on humeral shaft axis
 Abduction with flexion

26. Reduction
• Traction and counter traction

27. Film after reduction

28. Operative
• Failed closed reduction
• Soft tissue interposition
• Greater tuberosity fracture displaces > 1 cm.

29. Interlocking sling
• Age <45 : On interlocking sling 1-3 weeks
• Age >45 : until pain relieve, early ROM exercise

30. Rehabilitation
• Phase 1 (0-7 Days)
 Interlocking sling
 Isometric exercise, wrist and hand exercises
 Avoid positions that could cause re-dislocation 6 weeks
• Phase 2 (1-3 weeks)
 ROM movement, mobility exercise
• Phase 3 (3-6 weeks)
 isometric or static strengthening exercises

31. Greater tuberosity fracture
• Fracture proximal humerus
• Neer classification
• Displaced fracture
 Displaces > 1 cm
 Angulation > 45 degrees
• Tx
 Non-displaced : arm sling
 Displaced : ORIF with P&S

32. THANK YOU