ext ruj rujchasenee

1. Extern Conference
Extern รุจ รุจเศรณี

2. Patient profile
•ผู้ป่วยหญิงไทย อายุ 72 ปี มิลาเนา จังหวัดนครราชสีมา
Chief complaint
•ปวดข้อมือซ้าย 2 ชั่วโมงก่อนมารพ.

3. Primary survey
•A: can speak, no tender along C-spine
•B: trachea in midline, equal breath sound both lungs
•C: V/S stable, no active bleeding
•D: E4V5M6, pupil 3 mm RTLBE
•E: swelling left wrist with deformity ,no external wound

4. Secondary survey
•A: no Hx of drug allergy
•M: no medication
•P: no underlying
•L: NPO 20.00 น. (ถึง มหาราช 6.37 น.)
•E: หกล้มข้อมือซ้ายกระแทกพื้น 2 ชั่วโมง

5. Present Illness
•2 hr PTA ขณะกาลังลุกยืน เสียหลักล้มเอาข้อมือซ้ายยันพื้น
ปวดทันที บวมมากขึ้น มีผิดรูป ขยับไม่ได้ ไม่มีแผล บริเวณข้อมือ ไม่มี
ชาปลายมือ ไม่มีส่วนอื่นกระแทก

6. Past history
•Underlying disease – hypertension ,dyslipidemia
•ไม่เคยผ่าตัดมาก่อน
•ไม่ดื่มสุราหรือสูบบุหรี่

7. Physical examination
• Vital sign: BP = 140/90 mmHg, PR = 60 bpm, RR = 20 /min
• GA - A Thai elder female , alert, well co-operative
• HEENT - no pale conjunctiva, anicteric sclerae
• CVS - normal S1 S2, no murmur , no cyanosis, no jugular
vein engorged, no heave, no thrill
• RS - no accessory muscle used, trachea in midline,
symmetrical chest wall, resonance on percussion both
lungs, normal breath sound, no adventitious sound
• Abdomen soft, not tender , no guarding , no rebound
tenderness

8. Physical examination
•Extremities:
-Tender ,swelling ,dorsal surface deformity
-No external wound
-Limit ROM of left wrist
-Full ROM of left MCP,PIP,DIP and elbow joint
-Radial pulse 2+ both arm
•Neurology: sensory intact

12. Investigation
•Film both wrist AP , LAT

15. Diagnosis
•Distal end radius fracture left wrist
•Fracture ulnar styloid left wrist

16. Management at ER
•MO 4 mg IV stat before closed reduction
•Closed reduction with long arm AP slab

17. DISTAL END RADIUS FRACTURE
•Bimodal distribution
•Younger patient – high energy
•Older patient – low energy / falls
• Most common mechanism
•fall onto an outstretched hand with the wrist
in dorsiflexion

18. Clinical evaluation
•Swollen
•Ecchymosis
•Tenderness
•Painful range of motion
•Deformity

19. Physical examination
• Deformity, wound
• Point of tenderness
• Range of motion
• Neurovascular : pulse, median nerve (sensory)

20. Physical examination
• Shortened fracture radius and tilted in dorsal or volar
• Acute carpal tunnel syndrome – median nerve
• Open wound palmarly and ulnarly
• DRUJ injuries – shortening of radius over 5 mm must result in
disruption of the DRUJ ligaments
• Associate injuries – Elbow , shoulder
• Tendon injury – extensor pollicis longus
• Neurologic complication – Median nerve injury

22. Imaging study
•Radiograph – AP , Lateral view
•CT scan – evaluate intra-articular
involvement and surgical planning
•MRI – evaluate soft tissue injury eg. TFCC ,
Scapholunate ligament injuries

23. Parameters
•Dorsal or palmar tilt
•Radial length
•Radial inclination

27. Nonoperative treatment
• All fractures should undergo closed reduction , even if it is expected
that surgical management will be needed.
• Limit postinjury swelling ,provides pain relief ,relieves compression on the
median nerve
• Cast immobilize is indicated for
• Non displaced or minimally displaced fractures
• Displaced fractures with a stable fracture pattern which can be expected to
unite within acceptable radiographic parameters
• Low demand elderly patients

28. Acceptable radiographic parameter
•Radial length within 2-3 mm of the
contralateral wrist
•Palmar tilt Neutral tilt (0 degree)
•Intra-articular step-off < 2 mm
•Radial inclination < 5 degree loss
•Carpal malalignment absent

29. Lafontaine’s criteria
• Dorsal angulation > 20 degree
• Dorsal comminution
• Radiocarpal intra-articular involvement
• Associated ulnar fracture
• Age > 60 years
• If >/= 3 factors , early surgical intervention

30. Technique of close reduction
• Adequate pain relief – hematoma block , iv sedation
• Longitudinal traction and then direct pressure is appled on the
displaced radial metaphyseal fragment
• Radiograph after maneuver
• The position of immobilization of the radius should provide a dorsal
buttress to prevent collapse , but excessive palmar flexion of the
radius should be avoided(acute carpal tunnel syndrome)
• Worn cast approximately 6 weeks or until radiographic evidence of
union has occurred

32. Operative treatment
•Indication for surgery
• 1. Unstable
• Fernandez type II, IV ,V and some case in I , III
• Lafontaine criteria > 3 of 5 instability parameter
• Secondary displacement after casting
• 2.Irreducible fracture
• Double die punch
• Displaced comminuted PM fracture
• Articular step off > 2 mm
• Shortening > 5 mm

33. Operative treatment
• 3.Unacceptable alignment
• Radial inclination < 15 degree
• Shortening > 5 mm
• Dorsal tilt > 10 degree
• Volar tilt > 20 degree
• Articular step off or gap > 2 mm
• 4.Open fracture
• 5.Associate injury

34. Complication
• Malunion
• Neurologic injury
• Median nerve injury : acute carpal tunnel syndrome
• Ulnar nerve injury : Less common
• Complex regional pain syndrome
• Neuropathic pain temperature changes ,abnormal sweating ,swelling , joint
stiffness and athrophy
• Tendon injury - ruptures EPL , flexor tendon ruptures