Extern conference Ext.ณัชชา 12 ต.ค. 61

1. EXTERN CONFERENCE
EXT. NATCHA OOMSAP

2. • ผู้ป่วยชายไทยอายุ 37 ปี
• ภูมิลาเนา อ.ชุมพวง จ.นครราชสีมา
Patient Profile
Chief Complaint
• ปวดไหล่ซ้าย 1 วันก่อนมารพ.

3. • 1 วันก่อนมารพ. ขับMCล้ม โดนสุนัขตัดหน้า ไม่ได้สวมหมวกกันน็อค ไม่
สลบ จาเหตุการณ์ได้ เอาไหล่ซ้ายกระแทกพื้นถนน รู้สึกปวดบริเวณไหล่
ซ้าย บวม แต่ยกได้ ไม่มีชา มีแผลฉีกขาดที่หน้าผาก แขนขาเหยียดได้ เดิน
ลงน้าหนักได้ จึงมารพ.
Present Illness

4. • A : can talk, no C-spine tenderness
• B : equal breath sound both lungs,
CCT neg.
• C : BP 149/95 mmHg, PR 114 bpm
• D : E4V5M6, pupils 2 mm RTLBE
• E : LW 1*1 cm at forehead S/P suture
• AW 2*2 cm at Left shoulder
Primary Survey

5. AMPLE
• A : no food or drug allergy
• M : no current medication
• P : u/d HT
• L : last meal 9.00 น.
• E : MCล้มเอง ไหล่ซ้ายกระแทกพื้น มี
บาดแผลถลอกที่ไหล่ซ้าย
Secondary Survey Head To Toe Evaluation
• Heart : normal S1S2, no murmur
• Lungs : equal breath sound both lungs
• Abdomen : soft, not tender
• Extremities : LW 1*1 cm at forehead S/P
suture , AW 2*2 cm at Left shoulder
Tender at Lt shoulder, no limit ROM,
Lt Radial pulse 2+ , sensory intact
Duga’s test and empty can test negative
• Neurological : E4V5M6, pupils 2 mm
RTLBE

6. 6
INVESTIGATION

7. Shoulder AP/Transcapular view

8. 8
Both clavicle AP

9. • AC separation type V
Diagnosis
Management
• Admit
• Set OR for ORIF with TBW

10. Post operation : ORIF with TBW

11. Acromio-Clavicular Injuries
(AC Separation)

12. Introduction
 Definition
injury to the acromioclavicular (AC) joint with disruption of the AC ligaments with or without
coracoclavicular (CC) ligament disruption
 Epidemiology
 Incidence : common injury making up 9% of shoulder girdle injuries
 Demographics : more common in males and athletes
 Mechanism
- direct blow to the shoulder
- often sustained while falling onto the shoulder

13. Anatomy
 Osteology
 diarthrodial joint
- articulation of the scapula (medial acromion) and the lateral clavicle
- oblique orientation of joint surface
 contains a fibrocartilaginous intraarticular disc between the osseous elements
- analogous to the meniscus of the knee
 Motion : primarily gliding motion, rotational motion is minimal
 Stability
 acromioclavicular (AC) ligamentscontrols horizontal motion and anterior-posterior stability
 coracoclavicular (CC) ligamentscontrols vertical motion and superior-inferior stability

14. Presentation
 Symptoms
o pain
 usually over AC joint
 can also be referred to the trapezius
 Physical exam
o lateral clavicle or AC joint tenderness
o abnormal contour of the shoulder compared to contralateral side
 stability assessment
 horizontal (anterior-posterior) stability evaluates AC ligaments
- cross-body adduction
 vertical (superior-inferior) stability evaluates CC ligaments

15. Imaging
Radiographs
required views
 bilateral anteroposterior (AP) view of AC joints
 axillary lateral view : required to diagnose Type IV
(posterior)
additional veiws
 cross-body adduction view (Basmania) :
scapular Y performed with cross-body adduction stress
 weighted stress views
usually no longer used
may help differentiate Type II from Type III

16. Classification

17. Treatment
Nonoperative
brief sling immobilization, rest, ice,
physical therapy
indications
 type I and II
 type III in most individuals
(good results when clavicle displaced <
2cm)
rehab
 early shoulder range of motion
 regain functional motion by 6 weeks
 return to normal activity at 12 weeks
 consider corticosteroid injections
Operative
CC interval restoration (ORIF vs. Ligament
Reconstruction)
indications
• acute type IV, V or VI injuries
• acute type III injuries in laborers, elite
athletes, patients with cosmetic concerns
• chronic type III injuries that failed non-op
treatment
Contraindications
 patient unlikely to comply with
postoperative rehabilitation
 skin problems over fixation approach site
Rehabilitation
 sling immobilization for 6 weeks, no
shoulder range of motion
 return to full activity after 6 months

18. Complications
 Residual pain at AC joint
30-50%
 AC arthritis
more common with surgical management than with nonoperative
treatment
 chronic subluxation and instability
 Hardware failure
CC screw breakage/pullout

19. THANK YOU
FOR YOUR ATTENTION