Extern conference Ext.วรัมพร วันที่ 15 พ.ย. 61

1. Extern Conference
Warumporn Sinlapa PI

2. Patient profile
• ชายไทยอายุ 50 ปี
• ภูมิลาเนา อาเภอปักธงชัย จังหวัด นครราชสีมา
• ไม่มีโรคประจาตัว

3. History
• Cc : ปวดข้อมือขวา 6 ชั่วโมง ก่อนมาโรงพยาบาล
• PI : 6 ชั่วโมงก่อนมาโรงพยาบาล ขับรถจักรยานยนต์ ชนกับรถเก๋ง มีปวดบวมบริเวณข้อมือด้านขวา
และมีข้อมือผิดรูป กาและกระดกข้อมือได้น้อย ไม่มีศีรษะกระแทกพื้น ไม่สลบ สวมหมวกกันน๊อค จา
เหตุการณ์ได้ มา รพช Refer มา

4. Primary Survey
A : can speak, airway is patent , no tender along c-spine
B : normal breath sound ,equal both lungs CCT negative
C : BP 130/67 PR 86 , no active bleeding
D : E4V5M6 pupil 3mm RTLBE
E : swelling , tender and deformity at Rt wrist , no external
wound

5. Physical examination
GA : A Thai man , well cooperative
HEENT : not pale conjunctivae , an icteric sclerae
Chest : normal breath sound Both lungs
Abdomen & pelvis : soft, not tender
Musculoskeletal : swelling , tender and deformity at Rt
wrist , limit ROM , radial pulse 2+ , capillary refill < 2 sec
Neuro : Alert , can orientation to time place person
muscle grade V all except Rt upper lime can’ t evaluation
due to pain
Sensation > intact [ Radial nerve , median nerve , ulnar
nerve ]

6. Film Rt Wrist AP, Lat

7. Diagnosis
# Closed fracture distal end radius with intraarticular fracture

8. Management
- Hematoma block and Closed reduction
- On AP short arm slab

9. Film Rt Wrist AP, Lat
Radial height
Radial inclination

10. Film Rt Wrist AP, Lat
Volar tilt

11. Distal End radius
fracture

12. Introduction
Most common orthopaedic injury
- younger patients - high energy
- older patients - low energy / falls 50% intra-articular
Associated injuries
- Distal radial ulnar joint injuries
- radial styloid fx - indication of higher energy
- soft tissue injuries in 70%
Triangular fibrocartilage complex injury 40%
scapholunate ligament injury 30%
lunotriquetral ligament injury 15%
Osteoporosis
high incidence of distal radius fractures in women >50

13. Clinical evaluation
– Patients typically present with gross deformity of the
wrist with variable displacement of the hand in
relation to the wrist. Typically swollen with painful ROM
– Ipsilateral shoulder and elbow must be examined –
NV exam including specifically median nerve for
acute carpal tunnel compression syndrome

14. Fernandez classification
1987
แบ่งตามกลไกของแรงที่
กระทาต่อกระดูก

15. Type
– Colles Fracture
• Combination of intra and extra articular fractures of
the distal radius with volar angulation, dorsal
displacement, radial shift, and radial shortenting
• Most common distal radius fracture caused by fall
on outstretched hand
– Smith Fracture (Reverse Colles)
• Fracture with dorsal angulation from a fall on a
flexed wrist

16. Colles’ fracture
Low energy , dorsally displaced ,

17. Smith’s fracture
Low energy , volar displaced

18. Treatment
Treatment
– Displaced fractures require and attempt at reduction.
• Hematoma block of lidocaine in the fracture site
• Hang the wrist in fingertraps with a traction weight
• Reproduce the fracture mechanism and reduce the
fracture
– Operative Management
• For the treatment of intraarticular, unstable, malreduced
fractures.
Unstable: -Fernandez type II,IV,V and some case in I,III
-Lafontaine criteria≥3 of 5 instability parameters
-Secondary displacement after casting
• As always, open fractures must go to the OR.

20. Criteria for Acceptable Reduction
● Change in volar (palmar) tilt < 10° (ie, neutral or 20
palmar slope)
● Radial shortening < 2 mm
● Change in radial angle < 5°
● When intra-articular fracture is present:
Articular step-off < 1-2 mm

21. Radiographic evaluation

23. Thank you