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ศุภวิทย์ 5522122 case conference
- 2. Patient profile • ศศศศศศศศศศศศศ ศศศศ 75 ศศ . No U/D • ศศศศศศศศศศ ศ.ศศศศศศ ศ.ศศ. ศ.ศศศศศศศศศศ • ศศศศศ ศศศศศศศศศศศศ • ศศศศศศศศศศ ศศศศศศศศศศศ ศศศศ
- 3. Chief complain • ศศศศศศศศศศศศศศศศศศศศศศศ 4 hr PTA
- 4. Chief complain • ศศศศศศศศศศศศศศศศศศศศศศศ 4 hr PTA
- 5. Present illness • 4 hr PTA ศศศศศศศศศศศศศศศศศศศศ ศศศศศศศศศศศศศศศศศศศศศศศศศศ ศศศศศศศศศศศศศศศศศศศศศศศศ ศศศศศศศศศศศศศศศศศศศศศศ ศศศ ศศศศศศศศศศศศศศศศศศศศ ศศศศ ศศศศศศศศศศศศศศศศศศศศศศศศศศ ศศศศศศศศศศศศศศศ ศศศศศ
- 6. Primary survey • A : can speak , full active ROM of neck , not tender along C- spine • B : No stidor , no accessory muscle use ,equal breath sound • C : BP=130/78mmhg , HR=90bpm , Not seen external wound bleeding • D :E4V5M6 , Pupils 3 mmRTLBE
- 7. Primary survey • E : Not seen any external wound , Rt.arm seen abnormal mass at distal humerus area , not tender , full active&passive ROM of flexion+extension elbow , intact neurosensory and capillary refill <2 sec both upper extremities
- 9. Secondary survey • A : No food or drug allergy • M : No current medication • P : no underlying disease, Hx of gastric ulcer perforate มม มมมมมมมมมมม PEx->Peritonitis. มมมมมมมมม Explore lab with simple suture มมมมม20/9/54 มมมมมม มมมมมมมมมมม มม.มม มมมมมมมม no current medicationมมมม • L : Last meal 6 hr PTA มมมมมมมม • E : มมมมมมMcมมมมมมมมมมมมมม มมมมมม
- 10. Physical examination • GA : A elderly Thai man good consciousness, no external wound • HEENT : not pale conjunctiva ,anicteric sclera , No wound on maxillofacial no deformities , No cervical lymphadenopahy • Respi : trachea in midline , normal breath sound no adventiscious sound
- 11. Physical examination • Abdomen : seen surgical scar : flat shape, Soft not tender, normoactive bowel sound • Musculoskeletal : Rt.arm abnormal mass at distal humerus not tender , Full active ROM of Rt.shoulder,elbow,wrist ,hand • Neuro : Grossly intact all, No numbness or weakness both upper limb , muscle power Rt.elbow flexion power < Lt side (others equal power Gr.5)
- 12. Investigation • Film : • Rt.shoulder AP&Transcapular view • Rt.Humerus AP&Lat
- 16. Diagnosis • Rt. long head bicep tendon rupture
- 17. Management • Advice-> Pt.ตตตตตตตตตตตตตตตต conservative • On Rt.arm sling • ตตต F/U 2 week • HM • Paracetamol(500) 1 tab P.O. prn q 6 hr • Tramol 50 mg 1 cap P.O. prn
- 18. Bicep tendon rupture Reference : orthobullet (http://www.orthobullets.com/sports/3081/distal-biceps-avulsion)
- 19. Anatomy Reference : Netter’s clinical anatomy ; Edition2 ; chapter7 : upperlimb; page 313
- 20. Anatomy
- 21. Epidermology • Rare • Mostly in men (93%) • Mostly Proximal biceps tendon rupture( Distal -~10% ) • Rarely associate with median nerve injury
- 22. Risk factor • Age : Older > younger. (mostly often occur in Pt >40 Yr) • Heavy activity on weightlifting • Shoulder over use • Smoking • Corticosteroid medication
- 23. • Sign and Symptom • Sudden sharpe pain and in upper arm with audible‘‘Pop’’ or ‘‘Snap’’ Cramping of the bicep • Weakness in bicep function (Supination.. Flexion of elbow.)
- 24. • Sign and Symptom • Bulging of upper arm above elbow (Popeye sign) => Complete rupture
- 25. Hook test • Pt flex the elbow to 90° and to fully supinate the forearm • using index finger to hook the lateral edge of the biceps tendon. • false positive • partial tear • intact lacertus fibrosis • underlying brachialis tendon • sensitivity and specificity 100%
- 26. Hook test
- 27. Invetigation •X-rays • : usually normal but for R/O other problem ex. Fx or other shoulder and elbow problem • MRI
- 28. Treatment • Supportive • Indication • Older age ,Low demand for bicep function • Outcome • Patient will lose strenght of supination(50%) and flexion(30%) and grip(15%)
- 29. Treatment • Surgical • Anterior single incision technique • Dual incision technique • Distal biceps fixation technique