Download to read offline
More Related Content
ConferenceExt.
- 1. Case Conference EXT. SIRADACHUTCHUKIATKUL PHRAMONGKUTKLAO COLLEGE OF MEDICINE
- 2. Case • ผู้ป่วยหญิง อายุ66 ปี • สัญชาติไทย ศาสนาพุทธ • Chief complaint : ล้ม 2 ชั่วโมงก่นมาโรงพยาบาล • Present illness : 2 ชม. ก่อนมารพ. ผู้ป่วยสะดุดล้ม ใช้มือ ซ้ายยันพื้นขณะล้ม จากนั้นมีอาการปวดที่ข้อมือซ้าย กระดก ข้อมือไม่ได้ จึงมารพ.
- 3. Primary survey • A: can talk, not tender along C-spine • B : Spontaneous breathing, equal and clear breath sound both lungs, CCT negative • C : BP 126/76 mmHg, PR 88 bpm, no external bleeding • D : E4V5M6, Pupil 3 mm RTLBE • E : Tender and swelling at radial side of left wrist, Limit ROM of left wrist due to pain, cap refill < 2 sec, Radial artery 2+, Left fingers full ROM
- 4. Secondary survey • A: ปฏิเสธประวัติแพ้ยา แพ้อาหาร • M : ปฏิเสธยาที่ใช้ประจำ • P : ปฏิเสธประวัติโรคประจำตัว • L : NPO 12.00 น • E : สะดุดล้ม ใช้มือซ้ายยันพื้น เจ็บบริเวณข้อมือซ้าย ไม่มีส่วน อื่นกระแทก
- 5. Physical examination • GA: Good consciousness • HEENT : Not pale conjunctivae, no facial deformity, full ROM of neck, not tender along c-spine • Heart : Pulse full and regular, Normal S1S2, No murmur • Lungs: trachea in midline, equal chest movement, equal and clear breath sound both lungs, CCT negative • Abdomen, No distension, Soft, Not tender • Extremities : Tender and swelling at radial side of left wrist, Limit ROM of left wrist due to pain, cap refill < 2 sec, Radial artery 2+, Pinprick sensation intact, Left fingers full ROM • Neurological exam: E4V5M6, Pupil 3 mm RTLBE, Motor grade V all
- 6. Investigation • Film Leftwrist AP, Lateral
- 8. Diagnosis • Left distalend radius fracture (Fernandez type I)
- 9. Management • Sedation :MO 5 mg IV stat • Close reduction • Short arm AP slab
- 11.
- 12. Distal end radiusfracture • Approximately 16% of all fractures treated by orthopaedic surgeons • Three main peaks of fracture distribution: • Children age 5-14 • Males under age 50 (High velocity) • Females over the age of 40 years (Low velocity) • Elderly (Mostly extra-articular) • Young (Mostly intra-articular) • Elderly patient risk factors : Decreased bone mineral density, female gender and early menopause
- 13. Diagnosis • History ofmechanism of injury • A visible deformity of the wrist is usually noted, with the hand most commonly displaces in the dorsal direction. • The acute shortening of the radius relative to the ulna may manifest as an open wound palmarly and ulnarly where the intact ulna buttonholes through the skin • Movement of the hand and wrist are painful • Adequate and accurate assessment of the neurovascular status of the hand Is imperative. (Median nerve involvement – Carpal tunnel syndrome)
- 14. Diagnosis • Evaluation ofthe injured joint, and a joint above and below (ipsilateral elbow and shoulder joint) • Radiographs of the injured wrist (PA & Lateral) • Radiographs of other areas, if symptoms warrant
- 15. Anatomy • Scaphoid andlunate fossa • Ridge normally exists between these two • Sigmoid notch • Second important articular surface • Triangular fibrocartilage complex (TFCC) • Distal edge of radial to base of ulnar styloid
- 17.
- 19. Common Classifications • Gartland& Werley • Frykman (radiocarpal & radioulnar) • AO • Melone (impaction of lunate) • Fernandez (mechanism)
- 26.
- 28. Indications for ClosedTreatment • Low-energy fracture • Low-demand patient • Medical co-morbidities • Minimal displacement-acceptable alignment
- 29. • Apply well-moldedsplint or cast, with wrist in neutral to slight flexion • Check X-ray to confirm the acceptable reduction • Follow up x-rays needed in 1-2weeks to evaluate reduction • Change to short arm cast after 2-3 weeks, continue until fracture healing.
- 30. Indications for SurgicalTreatment • Unstable • Fernandez type II, IV, V and some case in I, III • Lafontaine criteria >3 of 5 instability parameters • Dorsal angulation >20 degree • Dorsal comminuted • Intra-articular radiocarpal fracture • Ulnar fracture • Age >60 • Secondary displacement after casting
- 31. Indications for SurgicalTreatment • Irreducible fracture • Double die punch • Displaced comminuted PM fragment • Articular step off > 2mm • Severe comminution • Shortening > 5mm
- 32. Indications for SurgicalTreatment • Unacceptable alignment • Radial inclination < 15 degree • Shortening > 5 mm • Dorsal tilt > 10 degree • Volar tilt > 20 degree • Articular step off or gap >2mm • Open fracture
- 33. Indications for SurgicalTreatment • Associated injury • Median Nerve Compression • Distal Radioulnar Joint injury • Carpal Ligament disruption • Partial or complete tear scapholunate ligament • Lunotriquetral ligaments tears 15%
- 34.