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- 2. *ผู้ป่วยหญิงไทยอายุ 47 ปี *Causeof injury : Motercycle accident *Chief complaint : ปวดไหล่ขวา 2 ชั่วโมงก่อนมาโรงพยาบาล
- 3. *A : Cantalk, C-spine not tender, Can flex neck *B : Normal breath sound equal both lungs, No open chest wound, Chest compression test negative, No distant heart sound *C : BP 137/78 mmHg, PR 82 bpm *D : E4V5M6, Pupil 3 mm RTLBE *E : No external bleeding, no wound, right shoulder swelling, position in abduction and external rotation
- 4. *A : Nodrugs or food allergy *M : No current medication *P : No underlying disease *L : 5/7/61เวลา 09:00 น. *E : 2 ชั่วโมงก่อนมาโรงพยาบาล ผู้ป่วยขับรถมอเตอร์ไซค์ล้มเอง โดยลื่นเสียหลัก หลังล้มไหล่ขวากระแทกพื้น ไม่มีศีรษะกระแทก ใส่หมวกกันน็อค จาเหตุการณ์ได้ตลอด ไม่มีชาหรืออ่อนแรง ไม่มีแผลเปิด ไม่สามารถขยับไหล่ ขวาได้เนื่ องจากเจ็บไหล่ขวามากจึงมาโรงพยาบาล
- 5. *GA : AThai female, alert well co-operative *HEENT : No pale conjunctiva, anicteric sclerae *Lungs : clear equal both lungs, CCT negative *Heart : Full regular rate and rhythm pulse, normal s1s2 no murmur *Abdomen : soft not tender, PCT negative *Neurological : E4V5M6, full EOM, pupils 2 mm RTLBE, motor power grade V all extremities, no sensation loss
- 6. *Extremities: right shoulderpositioning in abduction and external rotation, swelling with tenderness, limit ROM of right shoulder due to pain, intact sensation
- 9. *Anterior right shoulderdislocation with greater tuberosity of humerus fracture
- 10. *Shoulder reduction atright shoulder *Technique: Traction-Countertraction
- 15. *A shoulder dislocationdefinition is separation of the humerus from the scapula at the glenohumeral joint.
- 16. *Anterior: 97% - Fallonto outstretched hand - Force/blow to abducted and externally rotated +/- extended arm *Posterior: < 3% -50% secondary to trauma -34% associated with seizures *Inferior: < 1% -Hyperabduction injury -High rate of nerve and vascular injury
- 18. *Anterior shoulder dislocation -Arm is held in internally rotated and abducted position - Shoulder silhouette flattened with a prominent acromion
- 20. *Posterior -Arm is fixed,internally rotated, and adducted -Posterior shoulder prominence *Inferior -Fixed, abducted position -Arm held above the head
- 21. * *anteroposterior (AP) viewและ transcapular view (Y view)
- 26. *Hill-Sachs Leison: corticaldepression in the posterolateral head of the humerus
- 27. *Bankart Lesion: Detachmentof anterior inferior labrum from glenoid “Soft” – Labrum only “Bony” – impaction fracture involving glenoid margin
- 29. *Proximal humerus fractureประมาณร้อยละ 15 ของผู้ป่วยที่มี anterior shoulder dislocation จะมีการหักของ greater tuberosity ร่วมด้วย *Axillary nerve palsy *Axillary artery injury *Rotator cuff tear
- 30. *Shoulder reduction Techniques *Provideadequate analgesia *Complete a full neurologic and vascular assessment 1.Traction-Countertraction -Gradual, smooth traction is applied to the affected arm until patient’s muscles relax or tire sufficiently to release the dislocated humeral head -An assistant maintains counter traction to maintain patient in place
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- 33. *Shoulder reduction Techniques 3.Stimson maneuver
- 34. *Shoulder reduction Techniques 4.Scapular Manipulation -Stimsontechnique applied -Scapula manipulated : stabilized superiorly, medial force applied on inferior angle
- 35. *Post reduction filmsfor confirm the position of the humeral head *Pain control *Immobilization with arm sling for 3-4 weeks after shoulder reduction and early ROM(7-10days) with strenghtening excercise *Full function: 3-4 month
- 36. *Associated fracture ofhumeral neck *Associated nerve injury/deficit *Suspected major vascular injury *Chronic Dislocation *> 48 hours
- 37. Surgery indication *Irreducible shoulder(soft tissue interposition) *Displaced greater tuberosity fractures(>1cm) *Glenoid rim fractures bigger than 5 mm *Recurrent dislocation
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