Conference Ext.ธีรดนย์ & Ext.พราวนภัส 11.6.62

1. ORTHOPEDIC CONFERENCE
BY Ext.Prownapat , Ext.Teeradon 11/7/2019

2. Case เด็กชาย อายุ + ปี . เดือน
• CC : ล้มตกจากโต๊ะสูง +.= เมตร ? ชัAวโมงก่อนมารพ.
•PI :
• 2 hour PTA ล้มตกจากโต๊ะสูง +.= เมตร ไม่ทราบลักษณะท่าลง
ปวดแขนซ้าย แขนซ้ายบวม,ผิดรูป ไม่มีแผล ขยับแขนขวา และขาสองข้างได้
ปกติศีรษะไม่กระแทกพืPน ไม่หมดสติ ผู้ป่วยไม่ขยับแขนซ้าย จึงไปรพช. >
on arm sling แล้ว referมา MNRH

3. Past history
•No underlying disease
•No previous surgery/trauma
•No drug/food allergy
•No current medication

4. Physical Examination
• A : Can talk clearly ,Patent airway, no c-spine tenderness
• B : Clear,equal breath sound both lungs
• C : BP 139/78 mmHg, HR 120 bpm
• D : E4V5M6 , pupil 3mm RTLBE
• E : no external wound , no bleeding

5. Physical Examination
• Vital signs- BT 36.5 c, PR 90 bpm, BP 139/76,RR 20/min
• GA : A Thai boy, Alert, Good consciousness
• HEENT : no pale conjunctivae, anicteric sclerae
• CVS : Full, regular, symmetrical pulses all extremities,
normal s1,s2,no murmur
• Lungs : Normal breath sound in both lungs
• Abdomen : Soft ,not tender, normoactive bowel sound
• Back : not tender, no wound

7. Physical Examination
• Lt. elbow :
s shape deformity, swelling, no wound,
tenderness,
limit ROM due to pain,
distal neurological exam can’t evaluate
Capillary refill < 2 sec , radial pulse 2+, ulnar pulse 2+
• Lt. shoulder : no deformity, no wound, not tender, limit ROM due to pain
• Lt. hand : no deformity, no wound, not tender, limit ROM due to pain

8. • Other limbs : not tender , full ROM , no wound,
can active move
Physical Examination

9. Investigation
•Film Left elbow AP, lateral

11. Film interpretation
• Complete transverse fracture at supracondylar
region of left humerus with totally posteromedial
displacement
• Abnormal anterior humoral line and Baumann’s
angle
• +ve posterior fat pad sign
• surrounding soft tissue swelling

12. Diagnosis
Left supracondylar fracture Gartland type III

13. Parameters
• Baumann angle
Modified baumann N:64-81
Baumann N:9-26

14. • Anterior humeral line
> supracondylar fracture
Parameters
Anterior humeral line
capitellum

15. • Radiocapitellar line
> presence of radial head subluxation
or dislocation
Parameters

16. Supracondylar fracture
• Type
• Extension type(97.7%)
• Flexion type(2.3%)
• Clinical presentation
• Pain and swelling
• S-shaped deformity
• Loss of passive and active motions/pseudoparalysis

18. Supracondylar fracture
• Gartland’s Classification
I Non-displaced fracture
II Partially displaced , intact Posterior cortex
III Totally displaced

19. Gartland I

20. Gartland II

21. Gartland III

22. Treatment
• Initial
Temporary splint/ immobilize

23. • Gartland type 1 : Long arm cast / Locking slab
• Gartland type 2 : Close reduction + Long arm cast / Locking slab
+/- Pinning
• Gartland type 3 : Close reduction + Pinning + Long arm cast /
Locking Slab
Treatment

25. Operation Note

26. • Gartland type IV !!!!!
• Complete periosteal disruption with instability in flexion
and extension
• Diagnosed with examination under anesthesia during
surgery
• Treated with most commonly with CRPP or open
reduction if needed

27. Indication for open reduction
• 1. Inadequate reduction with close reduction
• 2. Vascular injury
• 3. Open fracture

28. Film post op.

30. Post operation care
• Elevation / swelling control
• Pain control
• Observe for compartment syndrome
• Observe for nerve , vessel injury
• Remove pins and cast at 3-4 weeks / union
• ROM exercise ,Strengthening exercise arm forearm, wrist, hand

31. Complications
• Early
1. Anterior interosseous nerve injury
2. Brachial artery injury
3. Compartment syndrome
• Late
1.Cubitus varus
2.Elbow stiffness