trauma case discussion

1. Case discussion
Extรามา ธนกร ปัทมาวไล

2. ชายไทยคู่ อายุ 65 ปี
CC : ปวดไหล่ซ้ายมาก 30 min PTA
PI : 30 min PTA ผู้ป่วยขับรถจักรยานยนต์ ถูกรถกระบะเฉี่ยวชน ตนจึงล้มรถจักรยานยนต์
กระเด็นออกจากรถ 2 m ไหล่ซ้ายกระแทกพื้น หลังจากนั้นปวดไหล่ซ้ายมาก ยกแขนซ้ายไม่ได้
ไม่สลบ รู้สึกตัวดีตลอดจาเหตุการณ์ได้ มีแผลถลอกตามตัว หายใจสะดวกดี ไม่เจ็บแน่นหน้าอก
กู้ภัยฮุก 31 จึงนาส่ง รพช.ปักธงชัย

3. Primary survey
• A : Airway patent ,can talk ,can move neck ,not tender along C spine
• B : no chest wound ,no dyspnea ,no accessory muscle used ,trachea in
midline ,clear and equal breath sound both lungs ,no adventitious
sound
• C : good consciousness ,BP 140/60 mmHg ,PR 80 / min
,no external bleeding
• D : E4V5M6 ,pupil 3 mm RTLBE ,can’t move Lt arm limit due to pain
• E :keep warm , multiple abrasion wound at Lt shoulder , Lt forearm
,and Lt knee ,not tender along spine

4. Adjunctive to primary survey
• CXR : Old fracture Lt. rib 2rd -5th ,no hemopneumothorax

6. Secondary survey
• Allergy : no history of drug or food allergy
• Medication : no current medication
• Past history : no known u/d
• Last meal :ประมาณ 18.00 น. 12/5/60 ข้าว
• Event : ตาม present illness
Refer จากรพช.ปักธงชัย

7. Physical examination
• GA : A Thai middle age man ,good consciousness
• Vital sign : BT 36.8c , BP 140/60 mmHg ,PR 80 bpm ,RR 20/min
• HEENT :not pale conjunctivae ,anicteric sclerae
• Skin : multiple abrasion wound
• Heart :normal S1,S2 ,no murmur , full and symmetrical pulse all exts.
• Lung no accessory muscle used ,trachea in midline ,normal breath sound ,no
adventitious sound
• Abdomen : not distend ,soft ,not tender
• Extremities : Abrasion wound 1x2cm at Lt shoulder, 1x5cm at Lt forearm and
2x3cm at Lt knee. No tenderness at forearm and knee
,stepping at mid shalf of Lt clavicle and tenderness ,limit ROM due to pain
,radial and brachial pulse 2 + ,normal deltoid sensation

9. Further investigation

10. Film Lt shoulder AP view Film Lt shoulder transcapular view

11. Diagnosis : Closed fracture middle shalf of Lt clavicle
and
closed fracture neck of left scapular
Floating shoulder

12. Management
Initial management
-asscess neurovascular injury
-immobilization with arm sling
Definite management
-Admit for surgery (ORIF)

13. Clavicle fracture
Mechanism -> direct blow to lateral aspect of shoulder
-> fall on an outstretched arm or direct trauma
Associated injuries
• ipsilateral scapular fracture
• scapulothoracic dissociation
• rib fracture
• pneumothorax
• neurovascular injury

14. Allman Classification
with Neer's Modification

15. Treatment
Non-operative
indication
Nondisplaced Gr I (middle third)
Stable GrII fracture(Type I,III,IV)
Anterior Gr III(medial third)
Choice
Figure of eight or arm sling immobilization
With gentle ROM exercise for 2-4 wks
Open reduction internal fixation
indications
• unstable Gr II fractures (Type IIA, Type IIB, Type V)
• open fxs
• displaced fracture with skin tenting
• subclavian artery or vein injury
• floating shoulder (clavicle and scapula neck fx)
• symptomatic nonunion
• posteriorly displaced Gr III fxs
• displaced Group I (middle third) with >2cm
shortening

16. Floating shoulder
coracoacromial (CA) ligament

17. Floating shoulder
• Ipsilateral fracture of clavicle and surgical neck of scapula.
• Rare , high-energy trauma
• Treatment
Non-operative immobilization
Operative ->ORIF of the clavicle alone (recommended )
->ORIF of both clavicle and scapular

18. The end