Ext.ธมลวรรณ 16 ก.ค. 61

1. Extern Conference
TAMONWAN PIANMANEE

2. Patient Profile
ผู้ป่วยเด็กชายไทย อายุ6 ปี 8 เดือน
ภูมิลาเนา จังหวัดนครราชสีมา
Chief complaint
แขนซ้ายผิดรูป 2 ชั่วโมง ก่อนมาโรงพยาบาล

3. Primary survey
A: Can speak, can flex neck, no tender along c-spine
B: Trachea in midline, equal breath sound, CCT negative
C: BP 105/68 mmHg, PR 92 bpm
D: E4V5M6, pupil 2 mm RTLBE
E: tender and deformity at left forearm, limit ROM,
no external wound

4. Secondary survey
A: no food or drug allergy
M: no current medication
P: no underlying disease
L: 13.00 น.
E: 2 hr PTA ผู้ป่วยเล่นโหนบาร์ที่สนามเด็กเล่น ตกจากบาร์ แขนซ้ายกระแทกพื้น ปวด
บวมที่แขนซ้าย แขนซ้ายผิดรูป ไม่มีชา ไม่มีแผลภายนอก ไม่เจ็บศอก ขยับนิ้วมือได้

5. Physical examination
General appearance: A Thai boy, good consciousness
Vital signs: PR 92 bpm, BP 105/68 mmHg, RR 20 /min
HEENT: not pale conjunctiva, anicteric sclera
Heart: normal S1 S2, no murmur
Chest: clear both lungs, equal breath sound
Abdomen: soft, not tender
Extremities: tender and deformity at left forearm, limit ROM,
radial pulse 2+, nerve intact, capillary refill < 2 sec

7. Investigation
Film Left forearm AP,lateral

8.  Film left forearm AP
Fracture both bone forearm
(incomplete fracture at distal ulna,completefracture with
displacementat distal radius )
 Film left forearm Lateral
Apex volarangulation

9. Diagnosis
 Closed fracture both bone left forearm

10. Management
 Pethidine 20 mg IV stat
 Closed reduction with AP long arm slab

11. Film Left forearm AP,lateral หลัง closed reduction

12. Fracture both bone forearm
in pediatrics

13. Anatomy

15. Fracture both bone forearm
in pediatrics
 One of the most common pediatric fractures
 Mechanism
- Indirect injury during fall on an outstretched hand
- Direct violence occassionally is cause of both bone forearm fracture

16. Type of fracture
incompletefractures of long bones and are usually
seen in young children,more commonly less than 10
years of age. They are commonly mid-diaphyseal,
affecting the forearm.
Greenstick fracture

17. Type of fracture
Non-displaced
The bone breaks completely, but the ends
remain lined up.

18. Displaced
The pieces of broken bone are not lined up
Type of fracture

19. Location
 Proximal:
- account for 5% of both bones fractures
- limited angulation will have greater effect on loss of motionthan will
more distal forearm fractures;
 Middle:
- account for 18% of both bones fractures;
- these fractures are often unstable and may be difficult to reduce with
casting due to the thickness of the overlying muscle mass
 Distal:
- account for 75% of fracture of the shaft of the radius and ulna

20. Symptoms
- forearm pain
- deformity
- Unable to move the arm normally
Physical exam
•swelling and focal tenderness
•neurovascular
•stepping
Presentation

21. Non-operative
• closed reduction and immobilization
indications
• most pediatricforearm fractures can be treated without surgery
• greenstickinjuries
• bayonet apposition < 1 cm if <10 years
Management

22. Table of Acceptable Reduction

23. Management
Non-operative
long arm cast 4-6 weeks, possible conversion to short arm cast
after 4 wks depending on fracture type and healing response
Position of wrist in cast varies with position of fracture
- most proximal 1/3 fracture need to be immobilized in supination
- most middle 1/3 ,distal 1/3 fracture should be placed in neutral
Follow up X-ray 1st-2nd week : ประเมิน Alignment

24. Management
Operative
Percutaneous vs open reduction and nancy nailing
Absolute indications
unacceptable alignment following closed reduction
angulation >15° in children <10y
angulation >10° in children >10y
bayonet apposition in children older than 10 years
both bone forearm fractures in children<13
Relativeindications
highly displacedfractures
Considerations
shorter surgical time than ORIF
less blood loss than ORIF

25. Management
Operative
Open reduction and internal fixation
Absolute indications
unacceptable alignmentfollowing closedreduction
angulation >15° in children <10y
angulation >10° in children >10y
bayonet apposition in children older than 10 years
open fractures
Refractures
both bone forearm fractures in children> 13
Relativeindications
highly displacedfractures

26. Complication
 Refracture
 occurs in 5-10% following both bone fractures
 is an indication for an ORIF
 Malunion
 loss of pronation and supination is common but mild
 Compartment syndrome
 may occur due to high energy injuries
 may occur due to multipleattempts at reduction
 Infection
 Synostosis

27. THANK YOU…