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Interesting Case Orthopedic
Extern. Vutthikorn Khingmontri (PCM)
CASE ผู้ป่วยเด็กชายไทยอายุ 9 ปี
HN 108-77-97
• Chief complaint : ปวดบริเวณแขนซ้าย 2 ชม PTA
• Present illness :
2 ชม PTA ผู้ป่วยตกต้นไม้ ความสูงประมาณ 2 เมตร มีแขนซ้ายกระแทกพื้น และหัวเข้าซ้ายกระแทกพื้น มี
อาการปวดบริเวณข้อมือซ้าย และมีข้อมือซ้ายผิดรูป ไม่มีบาดแผลตามตัว ไม่มีศีรษะกระแทก จาเหตุการณ์ได้ ไม่
สลบ
Primary survey
• A : Patent airway, no stridor, and no posterior cervical tenderness
• B : Equal chest expansion , trachea in midline, equal breath sound ,
both lungs clear
• C : Vital signs (BT = 37 c, PR =100 bpm, BP =120/70 mmHg, RR
=22/min), no external bleeding, no pelvic tenderness or
ecchymosis, abdominal soft not tender
• D : E4V5M6 , pupils 3 mm RTLBE
• E : Deformity at Left wrist, moderate tender, swelling at Left wrist,
PR: normal sphincter tone, yellow feces
Secondary survey
• A : no medical allergy
• M: No current medication usage
• P : U/D asthma
• L : Last meal = 19.45
• E : As present illness
Head to Toe Evaluation
• Vital sign: BT = 37 c, PR =100 bpm, BP =120/70 mmHg, RR
=22/min, BW= 44 Kg
• GA: Good consciousness, not pale
• HEENT : Not pale conjunctivae , anicteric sclerae , no
subconjunctivae hemorrhage, no evidence of head trauma, no
contusion
• Lungs : Equal chest expansion , equal breath sound , no accessory
muscle use , both lungs clear
• CVS : JVP not engorged , Pulse full and regular , Capillary refill < 2
sec , normal S1S2, no murmur
• Abdomen : No distention , soft , not tender , normoactive bowel
sound, no rigidity , no guarding , no rebound
• Extremities : tender at Left wrist, deformity at Left wrist, swelling ,
neurovascular intact, limit ROM due to pain
• Neuro : Good consciousness, well cooperative, good orientation to
time place person
• Motor : Grade V all extremities(except Left forearm due to pain)
• Sensory : Normal sensation to pain , temp and fine touch
Head to Toe Evaluation
Investigation: Film X-ray
• Film X-ray Left wrist AP
• Green stick fracture distal ulna with dorsal angulation
• Epiphyseal plate injury at distal end radius
• Dx: Closed fracture distal both bone forearm with epiphyseal plate
injury(Salter and Harris type 1)
Investigation: Film X-ray
Fracture in children
• Greenstick fracture
• Torus/Buckled fracture
• Plastic deformation
Distal forearm fractures in children
• Torus fracture
• Greenstick fracture
• Complete fracture
Epiphyseal plate or growth plate
injuries
• Salter-Harris classification
Most common
Anatomy epiphyseal plate
Salter-Harris type 1
Salter-Harris type 2 Thurston Holland’s sign
Salter-Harris type 3
Salter-Harris type 4
Salter-Harris type 5
Not clearly seen in x-ray
Treatment
Depends on
• Type of injury
• Age of patient
• Fracture stability
For type 1 & 2
• Closed reduction and immobilization in cast /splint/slab
• Immobilization for 3-6 weeks
• Check x-ray in7-10 days
Treatment
For type 3 & 4(intraarticular)
• Require anatomical realignment
• Closed or opened reduction
• ORIF with lag screws or kirschner wires running parallel to physis
• Immobilization 4-8 weeks
Treatment
For type 5
• Usually diagnosis retrospectively
• Gentle reduction
• Closed observation
• Surgical correction
Treatment
Complication
• Growth arrest(may be delayed for 2 years)(Most common
in type 4 & 5)
• Complete arrest: Length discrepancy
• Partial arrest: Angulation
• Growth acceleration
• Secondary osteoarthritis
Indication for surgery in pediatric
fracture
• Failed closed reduction
• Displace intraarticular fracture
• Displaced epiphyseal plate injury Salter-Harris type 3,4
• Children with multiple fracture or head injury
Management
4R
• Recognition
• Reduction
• Retention
• Rehabilitation
Management
• Pain control: pethidine 4 mg IV stat
• Closed reduction with long arm AP slab
Traction
Increase deformity
Reverse mechanism
Immobilization
Three
point
Conclusion
• Physeal injuries may not be readily obvious in children presenting
with periarticular trauma
• Treatment and follow up is essence to forestall future complication
Reference
• Rock wood and Wilkins fracture in children: Physeal injuries and
growth disturbance: E. Rathjen and Harry K.W. Kim
• Orthopedic trauma.ธีรชัย อภิวรรธกุล

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Interesting case orthopedic วุฒิกร^^

  • 1. Interesting Case Orthopedic Extern. Vutthikorn Khingmontri (PCM)
  • 2. CASE ผู้ป่วยเด็กชายไทยอายุ 9 ปี HN 108-77-97 • Chief complaint : ปวดบริเวณแขนซ้าย 2 ชม PTA • Present illness : 2 ชม PTA ผู้ป่วยตกต้นไม้ ความสูงประมาณ 2 เมตร มีแขนซ้ายกระแทกพื้น และหัวเข้าซ้ายกระแทกพื้น มี อาการปวดบริเวณข้อมือซ้าย และมีข้อมือซ้ายผิดรูป ไม่มีบาดแผลตามตัว ไม่มีศีรษะกระแทก จาเหตุการณ์ได้ ไม่ สลบ
  • 3. Primary survey • A : Patent airway, no stridor, and no posterior cervical tenderness • B : Equal chest expansion , trachea in midline, equal breath sound , both lungs clear • C : Vital signs (BT = 37 c, PR =100 bpm, BP =120/70 mmHg, RR =22/min), no external bleeding, no pelvic tenderness or ecchymosis, abdominal soft not tender • D : E4V5M6 , pupils 3 mm RTLBE • E : Deformity at Left wrist, moderate tender, swelling at Left wrist, PR: normal sphincter tone, yellow feces
  • 4. Secondary survey • A : no medical allergy • M: No current medication usage • P : U/D asthma • L : Last meal = 19.45 • E : As present illness
  • 5. Head to Toe Evaluation • Vital sign: BT = 37 c, PR =100 bpm, BP =120/70 mmHg, RR =22/min, BW= 44 Kg • GA: Good consciousness, not pale • HEENT : Not pale conjunctivae , anicteric sclerae , no subconjunctivae hemorrhage, no evidence of head trauma, no contusion • Lungs : Equal chest expansion , equal breath sound , no accessory muscle use , both lungs clear • CVS : JVP not engorged , Pulse full and regular , Capillary refill < 2 sec , normal S1S2, no murmur
  • 6. • Abdomen : No distention , soft , not tender , normoactive bowel sound, no rigidity , no guarding , no rebound • Extremities : tender at Left wrist, deformity at Left wrist, swelling , neurovascular intact, limit ROM due to pain • Neuro : Good consciousness, well cooperative, good orientation to time place person • Motor : Grade V all extremities(except Left forearm due to pain) • Sensory : Normal sensation to pain , temp and fine touch Head to Toe Evaluation
  • 7.
  • 8. Investigation: Film X-ray • Film X-ray Left wrist AP
  • 9.
  • 10. • Green stick fracture distal ulna with dorsal angulation • Epiphyseal plate injury at distal end radius • Dx: Closed fracture distal both bone forearm with epiphyseal plate injury(Salter and Harris type 1) Investigation: Film X-ray
  • 11. Fracture in children • Greenstick fracture • Torus/Buckled fracture • Plastic deformation
  • 12.
  • 13. Distal forearm fractures in children • Torus fracture • Greenstick fracture • Complete fracture
  • 14.
  • 15. Epiphyseal plate or growth plate injuries • Salter-Harris classification
  • 19. Salter-Harris type 2 Thurston Holland’s sign
  • 22. Salter-Harris type 5 Not clearly seen in x-ray
  • 23. Treatment Depends on • Type of injury • Age of patient • Fracture stability
  • 24. For type 1 & 2 • Closed reduction and immobilization in cast /splint/slab • Immobilization for 3-6 weeks • Check x-ray in7-10 days Treatment
  • 25. For type 3 & 4(intraarticular) • Require anatomical realignment • Closed or opened reduction • ORIF with lag screws or kirschner wires running parallel to physis • Immobilization 4-8 weeks Treatment
  • 26. For type 5 • Usually diagnosis retrospectively • Gentle reduction • Closed observation • Surgical correction Treatment
  • 27. Complication • Growth arrest(may be delayed for 2 years)(Most common in type 4 & 5) • Complete arrest: Length discrepancy • Partial arrest: Angulation • Growth acceleration • Secondary osteoarthritis
  • 28. Indication for surgery in pediatric fracture • Failed closed reduction • Displace intraarticular fracture • Displaced epiphyseal plate injury Salter-Harris type 3,4 • Children with multiple fracture or head injury
  • 29. Management 4R • Recognition • Reduction • Retention • Rehabilitation
  • 30. Management • Pain control: pethidine 4 mg IV stat • Closed reduction with long arm AP slab
  • 33.
  • 34. Conclusion • Physeal injuries may not be readily obvious in children presenting with periarticular trauma • Treatment and follow up is essence to forestall future complication
  • 35. Reference • Rock wood and Wilkins fracture in children: Physeal injuries and growth disturbance: E. Rathjen and Harry K.W. Kim • Orthopedic trauma.ธีรชัย อภิวรรธกุล