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Nithit case discussion
- 1. Extern conference BY NITHIT SEMSAWAT PI 5422054
- 2. ผู้ป่วยหญิงไทยคู่อายุ 58 ปี ภูมิลาเนา อาเภอเมือง จังหวัด นครราชสีมา สิทธิประกันสุขภาพถ้วนหน้า Chief complaint ล้มไหล่ซ้ายกระแทกพื้น 3 วัน PTA
- 3. Primary survey • A : can talk , no cervical spine tenderness , full ROM of neck • B : equal breath sound , no adventitious sound, CCT neg • C : BP 119 / 76 mmhg , PR 98/min , RR 20 / min , T 36 C , no visible site of active bleeding. • D : E4V5M6, pupil 3 mm RTLBE • E : No External wound
- 4. Secondary survey • A : no drug allergy • M : no current medication • P : no underlying disease • L : last meal 4 hr PTA • E : 3 day PTA ลื่นหกล้มไหล่ซายกระแทกพื้น เจ็บแขนซ้าย ยกแขนได้เล็กน้อยเนื่องจากปวด บวมเล็กน้อย ไม่มีแผลด้าน นอก ไม่มีอาการชาทีไหล่ ไม่มีเลือดออก ไม่มีอาการเจ็บบริเวณ อื่น ไม่สลบ ขยับข้อมือได้ปกติ
- 5. Physical examination • Vital signs : BP 119 / 76 mmHg , PR 98/min , RR 20 / min , T 36 C • General appearance : A Thai women good consciousness, well co operative • HEENT : not pale, no jaundice • Lung : clear , equal breath sound both • CVS : normal s1s2, no murmur • Abdomen : soft not tender • Neuro : E4V5M6 , orientated to time place person
- 6. Extremieties : Left shoulder • Tenderness, mild swelling, limited ROM due to pain, no deformity, no ecchymosis at left shoulder , no numbness at deltoid area • Brachial pulses 2+ • Radial pulse 2+ • No wrist drop
- 7. Investigation : Film left shoulder AP, Transcapular
- 8. Diagnosis CFX left humeral neck
- 9. Management • On Arm sling • F/U 2 wk + Film left shoulder AP, Transcapular • Home medication – Paracetamol [500] 1 tab oral prn for pain q 6 hr – Tramol [50] 1*3 oral prn for pain
- 11. Outlines • Epidemiology and risk factors • Signs and symptoms • Physical Examination • Radiographic findings • Neer classification • Indication for referral • Follow-up care • Return to sport or work
- 12. Epidemiology and risk factors • Incidence 4-5 % of all fractures • Incidence increases with age – > 70 % occurring in Pt. > 60 yr. • 3-4 times more common in females • Risk factors – Frequent falls – Low bone density
- 13. Signs and symptoms • Shoulder pain that increases with shoulder movement • Swelling and ecchymosis • Shoulder deformities
- 14. Physical Examination • No specific examination tests for diagnosis • Typically have focal tenderness at proximal humerus • Neurovasucular injury – Axillary nerve • Deltoid m. weakness • Decrease sensation of mid-deltoid region – Suprascapular nerve • Supraspinatous and infraspinatous m. weakness • Vasucular injury – Circumflex artery
- 19. Radiographic findings • Film shoulder AP , transcapular • CT with three dimensional reconstructions [if Plain film can’t diagnostic]
- 20. Film shoulder AP
- 22. Fracture patterns : Neer classification • Non – displace VS Displaced 1. Displaced > 1 cm 2. Angulation > 45 degrees • Fracture classified – One-part Fracture – Two-part Fracture – Three-part Fracture – Four-part Fracture Displaced Non-Displaced Displaced
- 26. Indication for referral • 80 % are non-displace or minimally displace – Can conservative at primary care clinicians • Displaced [2-4 part fractures]: need surgery – Refer to orthopedic surgeon for evaluation - Osteosynthesis - Percutaneous pinning - ORIF - Hemiarthroplasty • Emergency referral – all nerve and vascular injuries – Fracture dislocation
- 27. Initial treatment • Immobilization – Standard sling : impact fracture – Collar and cuff sling • Reduction of minimally displaced fragments – Swathes : use in shoulder unstable • Pain control • Ice : reduce pain and swelling • Pain control medication • Close reduction of fracture fragments is not recommended – Because several muscles have insertions on the proximal humerus
- 28. Follow-up care • Total healing is typically 6-12 wks • Early callus formation usually occurs a 4-6 wks • Duration of immobilization – 1-2 wks initiated ROM exercises
- 29. Follow-up care: Reevaluation • 7-14 days Reevaluation for significant displacement • If pain is well controlled and no displacement fragments – Pendulum exercises : decrease loss of shoulder motion – Isometric strengthening exercises for the biceps and triceps
- 31. Follow-up care : Subsequent visits • 2 - 4 wks after surgery – Encourage to discontinue their sling – Passive range of motion exercise of the elbow and shoulder : Twice daily • Pendulum exercise • Wall climbing exercise • Consult PT for passive ROM if necessary • Serial follow up q 2-4 wks for evaluation and improve range of motion
- 33. Follow-up care : Complications • Loss of shoulder mobility : most common • Neurovascular injury – Circumflex artery – Axillary or suprascapular nerve – Rotator cuff tear [if dislocation of humeral head ] • Osteonecrosis of Humeral head [uncommon]
- 34. Return to sport or work • Work : 3 wks after proximal humerus fracture – Not full use of the affected arm – 8-12 wks if jobs includes two-handed labor • Sports – Adequate range of motion – Strength as well as stable callus formation on radiographs
- 35. Take home message • Non displace fracture – Conservative – Early ROM exercise • Displace fracture – Refer to orthopedic surgeon for evaluation