Case discussion ortho jeen

1. Case Discussion
24 July 2017
Piengkwan Panutrakul

2. Patient profile
•เด็กชายไทย อายุ 6 ปี 6 เดือน
•ภูมิลาเนา อาเภอพิมาย จังหวัดนครราชสีมา
•สัญชาติไทย ศาสนาพุทธ
•สิทธิการรักษาบัตรทอง

3. History
 Chief complaint : ปวดแขนขวา 2 hr PTA
 Present illness : 2 hr ก่อนมาโรงพยาบาล เล่นกับเพื่อนที่โณงเรียน ตกจากศาลาสูงประมาณครึ่งเมตร ลาตัวด้านขวา ศอกขวา
กระแทกพื้น ไม่มีศรีษะกระแทก ไม่สลบ ศอกและแขนขวาปวด บวม ขยับแล้วเจ็บ กามือได้ไม่ชา จึงมาโรงพยาบาล
 Past history : โรคประจาตัว G6PD deficiency, ไม่แพ้ยาไม่แพ้อาหาร

4. Primary survey
 A : can speak ,can active movement of neck, not tender along c-spine
 B : trachea in midline, normal chest movement , normal breath sound equal both lungs
, CCT negative
 C : BP 106/55 mmHg PR 106 bpm , no external bleeding
 D : E4V5M6 , pupil 3 mm RTLBE
 E : right elbow marked swelling with deformities, no external bleeding, no wound ,limit
ROM due to pain, brachial and radial pulse 2+ cap

5. Secondary survey
 A : no food/drug allergy
 M : no current medication
 P : underlying disease G6PD deficiency , no surgical history
 L : last meal 8 hr
 E : ตกจากศาลาสูงประมาณครึ่งเมตร

6. Physical examination
 V/S : BT 36.6 C , BP 106/55 mmHg , PR 102 bpm ,RR 16 /min
 GA : A Thai girl , good conscious , well cooperative
 HEENT : not pale conjunctiva , anicteric sclera
 Heart : normal s1 s2 no murmur
 Lung : normal breath sound equal both lungs
 Abdomen : not distend , soft not tender
 Neuro : grossly intact

7. Physical examination
Extremity :
 right elbow marked swelling limit ROM pain
 deformity right arm
 brachial and radial pulse2+
 sensory intact
 capillary refil < 2 sec
 median,radial,ulnar nerve intact

8. Investigation

9. Diagnosis
Closed fracture left supracondylar of humerus (Gartland type III)

10. Treatment
 Close reduction
 check alignment by fluoroscope,close pinning
 On posterior long arm slab 4 wk

11. Post op

12. Supracondylar Fracture
 Most common fracture around elbow, usually found in age 5-10 year-old
 Incidence
- extension type most common (95-98%) the distal part of fracture displace posteriorly
- flexion type less common (<5%) %) the distal part of fracture displace anteriorly
 •mechanism of injury : fall on outstretched hand

13. Gartland Classification

14. Clinical presentation
 painful swollen elbow that the patient is hesitant to move
 Elbow angulated and the upper extremity shortened
 Some series report that open wounds are present in as many as 30% of these
fractures. Patient history includes a high-energy trauma or significant fall. Evaluate
adjacent joints for associated injuries.

15. Physical examination
 gross deformity , swelling , bruising , limited active elbow motion
 neurovascular exam - AIN ,median nerve, radial nerve
 vascular insufficiency : cold, pale, and pulseless , treat with
immediate reduction and pinning in OR, Attempted closed
reduction in ER first
 Median nerve, ulnar nerve, brachial artery are at risk

16. Radiographs
 AP and lateral x-ray of the elbow
 findings
- posterior fat pad sign : lucency along the posterior
distal humerus and olecranon
- displacement of the anterior humeral line

17. Treatment
 Gartland type I :Posterior long arm slab 70-80 degree for 2-3 weeks
 Gartland type II : closed reduction and posterior long arm slab at least 90 degree
flexion for 3-4 weeks
 Gartland type III : closed reduction under general anesthesia and fix with K wire
(Percutaneous pinning) and posterior long arm slab for 4 weeks

18. Complication
 Compartment syndrome espicailly in grade III and after reduction with flexion
 Cubitus varus : caused by fracture varus malunion pattern with little functional limitations
 Nerve palsy from injury
 Vascular Injury
 Postoperative stiffness

19. Thank you