Extern Conference ชยุตม์ 22 ธค.60

1. CONFERENCE
E X T. C H AY U D P R U E T L A PA K O R N
R A M AT H I B O D I H O S P I TA L

2. PATIENT PROFILE
•ผู้ป่วยเด็กชายอายุ 3ขวบ น้ำหนัก 15kg
•Cause of injury: ตกจากคันนา 2hr PTA
•เหตุการณ์เกิดเมื่อวันที่ 20 ธ.ค. 60 13.30น.

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PRESENT ILLNESS
•2hr PTA ขณะเล่นโดนเพื่อนผลักตกคันนา สูงประมาณ
1.5เมตร ไม่มีมีศีรษะกระแทก จำเหตุการณ์ได้ ไม่สลบ แขน
ขวากระแทกพื้น ข้อศอกขวาผิดรูป ปวดข้อศอกขวา ขยับไ
ได้ ไม่ชา ไม่มีส่วนอื่นกระแทกพื้น

4. PRIMARY SURVEY
•A: Can talk, not tender along C-spine
•B: Spontaneous breathing, equal breath sound both lung
CCT –ve
•C: BP 120/79 mmHg, PR 110 bpm, no external bleeding
•D: E4V5M6, pupil 2 mm RTLBE
•E: contusion, deformity at Rt elbow

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SECONDARY SURVEY -
HISTORY
•A: ปฏิเสธประวัติแพ้ยาและแพ้อาหาร
•M: ปฏิเสธประวัติการใช้ยาประจำ
•P: ปฏิเสธประวัติโรคประจำตัว
•L: NPO time 12.00
•E: ตกจากคันนาสูง 1.5เมตร

6. SECONDARY SURVEY –
EXAMINATION(1)
•Head & Maxillofacial:
no wound, no facial deformities, no ecchymosis
•C-spine & neck:
no wound, can move neck, C-spine not tender
•Chest:
equal breath sound both lungs, CCT –ve
•Abdomen & pelvis:
no wound, normoactive bowel sound, soft, not tender

7. SECONDARY SURVEY –
EXAMINATION(2)
• Musculoskeletal:
contusion wound at Rt elbow
swelling and marked tender at Rt elbow
radial pulse 2+ both, capillary refill <2sec, pinprick sensation in
Rt elbow limit ROM due to pain, can do Great-OK-ByeBye sign
• Neurological:
GCS: E4V5M6
CN: pupil 2mmRTLBE, no facial palsy
motor: grade V all extremities except Rt arm cannot evaluate

9. ELBOW AP/LAT

10. ELBOW INJURY
• Baumann angle
• Humeroulnar angle
• Fat pad sign
• Coronoid line>> ดู posterior displacement of lateral condyle
• Tear drop
• Ant. Humeral line
• Radiopcapitellar line

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BAUMANN ANGLE
• Shaft-physeal angle
• Long axis of shaft humerus , inclination of capitellae physis
• Not equal to carrying angle in older children
• Compared both sides (<5-8°)

12. TEARDROP
• Anterior : posterior of coronoid fossa
• Posterior : anterior of olecranon fossa
• Inferior : ossification center of capitellu

13. DIAGNOSIS
•Closed, displaced fracture of supracondylar of right
humerus, Gartland type3

14. MANAGEMENT
•Closed reduction with percutaneous pinning under gener
anesthesia
•Immobilization with posterior long arm slab

16. POST-OP CARE
•Elevation/ swelling control
•Pain control
•Observe for compartment syndrome
•Remove pins and cast at 3-4wks/ union

17. SUPRACONDYLAR
FRACTURE OF
HUMERUS
E X T. C H AY U D P R U E T L A PA K O R N
R A M AT H I B O D I H O S P I TA L

18. SUPRACONDYLAR
FRACTURE OF HUMERUS
• Peak age 5 - 7 years (average 6.7 years)
• Extension type 97-99%
• Nondominant side predominates
• Mechanism: Hyperextension load on the elbow from falling on
outstretched arm

19. SIGN AND SYMPTOMS
•Pain
•Limit ROM
•Bruising
•Gross displacement
•Pucker sign
•Assessment to associated trauma

20. CLASSIFICATION(1)
• Extension type (97%): “S-shaped Configuration”
• Flexion type (3%)

21. CLASSIFICATION(2)

22. GARTLAND

23. MANAGEMENT(1)
Initial : Splinting with the elbow 20 - 40 degrees of flexion
Type I: Long-arm cast, 60-90 degree of elbow flexion,3 wks
Type II: CR with pinning*(start two lateral pin) > Cast
Type III: CR with pinning(some recommended 3 pins) or Open
reduction
Type IV: Open reduction + two K-wires fixation

24. MANAGEMENT()
•Many of these are stable after closed reduction and castin
90 to 100 degrees of flexion (130). When more than 100
degrees of flexion is required for maintenance of reducti
percutaneous pinning is recommended
•Type II ต้องดูระหว่าง degree of elbow flexion for stabilit
VS Risk of compartment syndrome
– If more degree of elbow flexion ->recommend pin fixation

25. INDICATION FOR OPEN
REDUCTION
•Inadequate reduction with closed methods
•Vascular injury
•Open fractures

26. COMPLICATION
• Cubital varus: Most common
• Loss of motion: Posterior approach
• Myositis ossification
• Osteonecrosis: Trochlear, fishtail deformity
• Compartment syndrome <1%
• Vascular injury
• Nerve injury: Most common>> AIN

27. COMPLICATION: VASCULAR
COMPROMISE
The pulse usually returns within 48hr