Download as PDF, PPTX
More Related Content
Ortho pom (1)
- 1. EXTERN CONFERENCE Ext. Thanyakorn Chirakunakorn Facultyof medicine, Ramathibodi hospital 29 June 2018
- 2. CASE • หญิงไทยคู่อายุ 59ปี ภูมิลาเนา จ.นครราชสีมา • CC : ล้มมือซ้ายกระแทกพื้นมา 1 hr PTA • Present illness: 1 hr PTA ขณะกาลังพยุงตัวลุกจากแคร่นั่ง ฝนตกจึงเกิดลื่นเสียหลัก เอามือซ้ายลง มีอาการปวดบวมที่ข้อมือซ้าย มีข้อมือผิดรูป ไม่มีศีรษะกระแทกพื้น ไม่สลบ จา เหตุการณ์ได้ ไม่ได้รับบาดเจ็บบริเวณอื่น • No known underlying disease
- 3. PRIMARY SURVEY A :Can talk, C-spine not tender, Can flex neck B : trachea in midline,RR 20 bpm, Normal breath sound equal both lungs, No open chest wound, Chest compression test negative, No distant heart sound C : BP 166/92 mmHg, PR 96 bpm, PCT negative D : E4V5M6, Pupil 3 mm RTLBE E : No external bleeding, No external wound, left wrist deformity
- 4. Dinner fork/ silverfork deformity
- 5. SECONDARY SURVEY • Allergy: no food/drug allergy • Medication : no current medication • Past history : Tubal ligation 20 years ago • Last meal : 4 hr PTA • Event : as in present illness
- 6. PHYSICAL EXAMINATION • GA:A Thai elderly woman, well cooperate • HEENT: Not pale conjunctivae, anicteric sclerae • CVS: normal s1 s2, no murmur • Lungs: clear equal both lungs • Abdomen: soft, not tender • Neuro: E4V5M6, pupil 3mm RTLBE • Extremities: Lt.wrist: deformity,marked swelling,tender,redness, crepitation, stepping, limit ROM,Radial pulse 2+, intact nerve,cap refill<2s
- 7.
- 8. MANAGEMENT • Hematoma block •Close reduction • On AP short arm slab
- 9. DIAGNOSIS : CLOSED FRACTUREAT LEFT DISTAL END RADIUS FRACTURE (COLLES’ FRACTURE)
- 10. • Most commonfractures of the upper extremity in younger and older patients. • Occur through the distal metaphysis of the radius • May involve articular surface frequently involving the ulnar styloid DISTAL END RADIUS FRACTURE
- 11.
- 12. • Most commonlya fall on an outstretched extremity with the wrist in dorsiflexion, impact loading of distal radius • Younger patient – high energy • Older patient – low energy/ fall • High energy may result in significantly displaced, highly unstable fracture • 50 % intra-articular • High incidence of distal radius fracture in women >50 years old relate with osteoporosis MECHANISM OF INJURY
- 13. CLINICAL EVALUATION • Openwound (common occur in ulnar side) • gross deformity of the wrist • swollen • Tender on palpitation – fracture site • Limit and painful ROM –> Ipsilateral shoulder and elbow must be examined • Neurovascular exam paresthesia/numbness ->median nerve for acute carpal tunnel compression syndrome
- 14. ASSOCIATED INJURY • Associatedinjuries - DRUJ injuries must be evaluated • radial styloid fx - indication of higher energy • soft tissue injuries in 70% – TFCC injury (Triangular Fibrocartilage Complex) 40% – scapholunate ligament injury 30% – lunotriquetral ligament injury 15%
- 15. • 3 viewof the wrist including true PA(PA zero), Lateral +/- Oblique • Oblique view – useful for assess radial comminution, depression of radial styloid • CT scan is selected in some cases ; Intraarticular fractures with multiple fragments, centrally impacted fragments, DRUJ incongruity RADIOGRAPHIC EVALUATION
- 18.
- 19.
- 20. RADIOGRAPHIC FINDINGD • Extraor intra-articular fracture • Dorsal angulation • Dorsal tilt • Dorsal comminution • Radial shortening • Ulnar styloid fracture • ( Ulnar variance )
- 21. CLASSIFICATION • Fernandez: basedon mechanism of injury** • Frykman: based on joint involvement (radiocarpal and/or radioulnar) +/- ulnar styloid fx • Melone: divides intra-articular fxs into 4 types based on displacement • AO: comprehensive but cumbersome • Eponyms: see table for list of commonly used eponyms
- 22. Colles Fracture • Combinationof intra and extra articular fractures of the distal radius with dorsal angulation (apex volar), dorsal displacement, radial shift, and radial shortenting • Most common distal radius fracture caused by fall on outstretched hand Smith Fracture (Reverse Colles) • Fracture with volar angulation (apex dorsal) from a fall on a flexed wrist Barton Fracture • Fracture with dorsal or volar rim displaced with the hand and carpus Radial Styloid Fracture (Chauffeur Fracture) • Avulsion fracture with extrinsic ligaments attached to the fragment • Mechanism of injury is compression of the scaphoid against the styloid
- 23.
- 24.
- 25. CLOSED REDUCTION • Hematomablock 8-10cc of 1% lidocaine without adrenaline in the fracture site • longitudinal traction + wrist ulnar deviate assistant (manual) or chinese finger trap 5 kg, 5 minutes • Increase deformity Reverse mechanism Reapposition Decrease deformity • If still have stepping, try reduction again • arm cast/ AP slab with three point fixation (short sab/cast prefer for olderly) • X-ray confirm
- 26. 1.Unstable type -Fernandez typeII,IV,V and some cases in I,III Lafontaine criteria≥3 of 5 instability parameters -Secondary displacement after casting 2. Irreducible fracture 3. Unacceptable aligment 4. Open fractures 5. Associated injury INDICATION FOR SURGERY
- 27. Unacceptable alignment • Radialinclination < 15o • Shortening > 5 mm • Dosal tilt > 10o • Volar tilt > 20o • Articular step off or gap > 2 mm Irreducible fracture • Double die punch • Displaced comminuted PM fragment • Articular step > 2 mm • Severe comminution • Shortening > 5 mm
- 29. COMPLICATION • Compartment syndrome •Median nerve neuropathy • Distal radio-ulnar joint instability • Post-traumatic arthritis • Malunion
- 30. ADVICE - เป็นโรคอะไร ได้รักษาอะไรไปบ้างจาเป็นต้องผ่าตัด หรือไม่ ในกรณีไม่ต้องผ่าตัด ต้องใส่เฝือกนานอย่างน้อย 4 สัปดาห์ - ใน 24 ชั่วโมงแรก ถ้ามีอาการแขนบวมมากขึ้น ชามากขึ้น ขยับได้น้อยลง ให้มาพบแพทย์โดยเร็ว - เริ่มขยับข้อข้างเคียง เช่น นิ้วมือ ข้อศอก หัวไหล่ กันข้อติด แข็ง - หากคัน อาจโรยแป้ง กินยาแก้แพ้ได้ ไม่ควรใช้วัตถุแหย่ เข้าเฝือก - หากมี osteoporosis ให้รักษาต่อไป
- 31. TREATMENT GOALS • Preservehand and wrist function • Realign normal osseous anatomy – articular surface • Promote bony healing • Allow early finger and elbow ROM Pain control + follow up clinical and film 1-2 weeks are important
- 32. Recognition Lifethreatening condition Resuscitation save life Re-evaluation complete systematic evaluation Reduction Retention fracture-dislocation Rehabilitation Reconstruction PRINCIPLE OF TRAUMA ORTHOPEDIC CASES
- 33. REFERENCE • Rockwood andGreen’s, Fractures in Adults, eighth edition • https://www.orthobullets.com • http://www.aopublishing.org/ • http:// plasticsurgerykey.com/management-of-wrist-fractures/
- 34.