Ref. www.orthobullets.com

1. EXTERN CONFERENCE
Ext. ฐิติยาภรณ์ พิมวรรณ์ PIMD/B

2. Patient Profile
• ผู้ป่วยชายไทยคู่ อายุ 70 ปี
• ภูมิลาเนา อาเภอ ด่านขุนทด จังหวัดนครราชสีมา
• สัญชาติไทย นับถือศาสนาพุทธ
• สิทธิการรักษา บัตรประกันสุขภาพถ้วนหน้า

3. • Chief complaint :
ขับมอเตอร์ไซค์ล้ม 6 ชั่วโมงก่อนมา รพ.
• Present illness :
6 ชั่วโมงก่อนมารพ. ระหว่างขับรถมอเตอร์ไซค์ล้มเอง ไม่สลบ มือขวายันกระแทก
พื้น หลังจากนั้นมีอาการปวดบริเวณปลายนิ้วก้อย และมีแผลฉีกขาดบริเวณนิ้วกลาง และ
นิ้วนาง นิ้วอื่นยกเว้นนิ้วก้อยขยับได้ดี ไม่มีอาการชาที่มือ ไปรพช. ได้รับการรักษาเบื้องต้น
และ refer มารพ.มหาราชนครราชสีมา

4. Past history :
- ปฏิเสธโรคประจาตัว
- ไม่แพ้ยา
- ไม่แพ้อาหาร

5. Primary survey
A : can speak, can active movement of neck, c-spine not
tender
B : trachea in midline, normal chest movement , normal
breath sound equal
both lung , CCT negative
C : BP 173/88 mmHg PR 120 bpm
D : E4V5M6 , pupil 3 mm RTLBE
E : avulsion wound 10 cm and oFX seen bone and tendon
can flexion Right little finger, tender, capillary refill time <
2 sec, no numbness ; Laceration wound

8. Secondary survey
A : no food/drug allergy
M : no current medication
P : no underlying disease , no surgical history
L : last meal 6 hr
E : ขับรถมอเตอร์ไซค์ล้มเอง แขนขวายันกระแทกพื้นถนน

9. Physical examination
GA : A Thai man , good consciousness , well
cooperative
V/S : BT 36.5 C , BP 173/88 mmHg , PR 120 bpm ,RR 20
/min
HEENT : no pale conjunctiva , anicteric sclera
Heart : normal s1 s2 no murmur
Lung : normal breath sound equal both lung
Abdomen : no distension, soft, not tender
Neuro : grossly intact

10. INVESTIGATI

11. Film Right little finger AP, Lateral
Comminuted Fx at tuft of distal and base of
middle phalanx with anterior dislocation of DIP
with mallet finger of Right little finger

12. Film Right middle finger lateral
Not seen fracture at Right middle finger

13. Film Right hand AP, Oblique
Comminuted fracture at distal phalanx of Right
little finger

14. Diagnosis
• oFX distal and middle phalanx of
Right little finger with partial tear
lateral band at ulnar side of Right
middle finger

15. Management
• NPO, 5%DN/2 1000 ml i.v. rate 80 ml/hr
• Pre-operative LAB : CBC, BUN, Cr, Electrolyte, anti-
HIV
• EKG 12 leads
• CXR
• Cefazolin 1 gm i.v. q 6 hr with stat
• Set OR for Debridement with repair lateral band
Middle finger and
Closed stump Rt. Little finger

16. Post operative care
ONE DAY
- Routine post-op care
- ตื่นดี กินได้
- IV หมด off IV , on HL
- MO
4mg i.v. prn for pain q 6 hr
- Plasil
10 mg i.v. prn for N/V q 6 hr
CONTINUE
- Regular diet
- Record V/S
- Medications
- Paracetamol
1 tab p.o. prn for pain q 6 hr
- Cefazolin
1 gm i.v. q 6 hr

17. Open fractu
definition
a fracture with direct communication to the

18. Objective of open fracture treatment
1. Prevention and treatment of infection
2. Solid bone healing
3. Function of limb

19. Gustilo and Anderson classification of open
fractures
Type I:
- Clean wound smaller than 1 cm in diameter
- Simple fracture pattern
- No skin crushing
Type II:
- a laceration larger than 1 cm
- No significant soft tissue crushing
- Fracture pattern may be more complex

20. Type III:
- Contamination : soil ,water , yard ,fecal
- Open segmental fracture or a single fracture with extensive
soft tissue injury
- Any opened fracture older than 8 hours
• Type IIIA: adequate soft tissue coverage of the fracture
despite high energy trauma or extensive laceration or skin
flaps.
• Type IIIB: inadequate soft tissue coverage with periosteal
stripping. Soft tissue reconstruction is necessary.
Gustilo and Anderson classification of open
fractures (con’t)

21. Basic Principles of Open Fracture Management in
the Emergency Room
• Fracture management begins after initial trauma survey
and resuscitation is complete
• Antibiotics : initiate early IV antibiotics and update
tetanus prophylaxis as indicated
• Control bleeding : direct pressure will control active
bleeding and do not blindly clamp or place tourniquets
on damaged extremities
• Assessment : soft-tissue damage, neurovascular exam
• Dressing : remove gross debris from wound, place
sterile saline-soaked dressing on the wound
• Stabilize : splint fracture for temporary stabilization (
decreases pain, further injury from bone ends, and
disruption of clots )

22. Basic Principles of Open Fracture Management in
the Operating Room
• Aggressive debridement and irrigation
• Fracture stabilization : can be with internal or external
fixation, as indicated
• Staged debridement and irrigation : perform every
24 to 48 hours as needed
• Early soft tissue coverage or wound closure is ideal
• Can place antibiotic bead-pouch in open dirty wounds
:
beads made by mixing methylmethacrylate with heat-
stable antibiotic powder

23. Antibiotic Treatment
• Gustilo Type I and II
o 1st generation cephalosporin
o clindamycin or vancomycin can also be used if allergies exist
• Gustilo Type III
o 1st generation cephalosporin and aminoglycoside
• Farm injuries or possible bowel contamination
o add penicillin for anaerobic coverage (clostridium)
• Duration
o initiate as soon as possible
o studies show increased infection rate when antibiotics are delayed for
more than 3 hours from time of injury
o continue for 24 hours after initial injury if wound is able to be closed
primarily

24. Tetanus Prophylaxis
• Initiate in emergency room
• Two forms of prophylaxis
o toxoid dose 0.5 mL, regardless of age
o immune globulin dosing
 <5-years-old receives 75U
 5-10-years-old receives 125U
 >10-years-old receives 250U
• Guidelines for tetanus prophylaxis depend on 3 factors
o complete or incomplete vaccination history (3 doses)
o date of most recent vaccination
o severity of wound