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Case discussion ortho jeen
- 1. Case Discussion 24 July 2017 Piengkwan Panutrakul
- 2. Patient profile •เด็กชายไทย อายุ 6 ปี 6 เดือน •ภูมิลาเนา อาเภอพิมาย จังหวัดนครราชสีมา •สัญชาติไทย ศาสนาพุทธ •สิทธิการรักษาบัตรทอง
- 3. History Chief complaint : ปวดแขนขวา 2 hr PTA Present illness : 2 hr ก่อนมาโรงพยาบาล เล่นกับเพื่อนที่โณงเรียน ตกจากศาลาสูงประมาณครึ่งเมตร ลาตัวด้านขวา ศอกขวา กระแทกพื้น ไม่มีศรีษะกระแทก ไม่สลบ ศอกและแขนขวาปวด บวม ขยับแล้วเจ็บ กามือได้ไม่ชา จึงมาโรงพยาบาล Past history : โรคประจาตัว G6PD deficiency, ไม่แพ้ยาไม่แพ้อาหาร
- 4. Primary survey A : can speak ,can active movement of neck, not tender along c-spine B : trachea in midline, normal chest movement , normal breath sound equal both lungs , CCT negative C : BP 106/55 mmHg PR 106 bpm , no external bleeding D : E4V5M6 , pupil 3 mm RTLBE E : right elbow marked swelling with deformities, no external bleeding, no wound ,limit ROM due to pain, brachial and radial pulse 2+ cap
- 5. Secondary survey A : no food/drug allergy M : no current medication P : underlying disease G6PD deficiency , no surgical history L : last meal 8 hr E : ตกจากศาลาสูงประมาณครึ่งเมตร
- 6. Physical examination V/S : BT 36.6 C , BP 106/55 mmHg , PR 102 bpm ,RR 16 /min GA : A Thai girl , good conscious , well cooperative HEENT : not pale conjunctiva , anicteric sclera Heart : normal s1 s2 no murmur Lung : normal breath sound equal both lungs Abdomen : not distend , soft not tender Neuro : grossly intact
- 7. Physical examination Extremity : right elbow marked swelling limit ROM pain deformity right arm brachial and radial pulse2+ sensory intact capillary refil < 2 sec median,radial,ulnar nerve intact
- 9. Diagnosis Closed fracture left supracondylar of humerus (Gartland type III)
- 10. Treatment Close reduction check alignment by fluoroscope,close pinning On posterior long arm slab 4 wk
- 11. Post op
- 12. Supracondylar Fracture Most common fracture around elbow, usually found in age 5-10 year-old Incidence - extension type most common (95-98%) the distal part of fracture displace posteriorly - flexion type less common (<5%) %) the distal part of fracture displace anteriorly •mechanism of injury : fall on outstretched hand
- 14. Clinical presentation painful swollen elbow that the patient is hesitant to move Elbow angulated and the upper extremity shortened Some series report that open wounds are present in as many as 30% of these fractures. Patient history includes a high-energy trauma or significant fall. Evaluate adjacent joints for associated injuries.
- 15. Physical examination gross deformity , swelling , bruising , limited active elbow motion neurovascular exam - AIN ,median nerve, radial nerve vascular insufficiency : cold, pale, and pulseless , treat with immediate reduction and pinning in OR, Attempted closed reduction in ER first Median nerve, ulnar nerve, brachial artery are at risk
- 16. Radiographs AP and lateral x-ray of the elbow findings - posterior fat pad sign : lucency along the posterior distal humerus and olecranon - displacement of the anterior humeral line
- 17. Treatment Gartland type I :Posterior long arm slab 70-80 degree for 2-3 weeks Gartland type II : closed reduction and posterior long arm slab at least 90 degree flexion for 3-4 weeks Gartland type III : closed reduction under general anesthesia and fix with K wire (Percutaneous pinning) and posterior long arm slab for 4 weeks
- 18. Complication Compartment syndrome espicailly in grade III and after reduction with flexion Cubitus varus : caused by fracture varus malunion pattern with little functional limitations Nerve palsy from injury Vascular Injury Postoperative stiffness
- 19. Thank you