Extern conference ศนิ 8 มิ.ย. 61

1. EXTERN CONFERENCE
Sani Thaniwattananon 8th June 2018

2. PATIENT PROFILE
ผู้ป่วยหญิงไทยคู่ อายุ 43 ปี
ภูมิลาเนา อาเภอเมือง จังหวัดนครราชสีมา

3. CAUSE OF TRAUMA
ลื่นล้ม
ปวดข้อศอกขวา 1 ชั่วโมงก่อนมาโรงพยาบาล
CHIEF COMPLAINT

4. PRESENT ILLNESS
1 ชั่วโมงก่อนมาโรงพยาบาล ลื่นล้ม แขนขวากระแทกพื้น ไม่มีศีรษะกระแทกพื้น ไม่
สลบ จาเหตุการณ์ได้ ไม่มีบาดแผล ไม่มีเลือดออก หลังจากนั้นงอและเหยียดข้อศอก
ขวาไม่ได้ บวม ปวดข้อศอกขวามากขึ้นจึงมาโรงพยาบาลฯ

5. PRIMARY SURVEY
A : Can speak, can flex neck, no tenderness along c-spine
B : Trachea in midline, equal breath sound, CCT negative
C : BP 132/71 mmHg, HR 93 bpm
D : E4V5M6, pupils 2 mm RTLBE
E : No external wound, tender along right elbow, limit ROM due to
pain, mild swelling

6. SECONDARY SURVEY
A : no food or drug allergy
M : no current medication
P : no underlying disease
L : 3 hours ago
E : as present illness

7. PHYSICAL EXAMINATION
Airway and breathing : spontaneous breathing
Vital signs : HR 93 bpm, BP 132/76, RR 16/min
HEENT : no external wound,
C-spine : no posterior midline neck pain, no soft tissue
contusion or swelling around the neck
Chest : normal breath sound, equal
Abdomen : soft, not tender

8. PHYSICAL EXAMINATION
Extremities : no external wound, tender along right elbow, mild
swelling, limit both flexion and extension, slightly flexion
position (20-30◦)
Radial & ulnar pulses 2+, capillary refills < 2 sec
Normal pinprick sensation
Can adduct/abduct thumb, can extend wrist
No tenderness along wrist and shoulder

9. INVESTIGATION : FILM RIGHT ELBOW AP,LATERAL

10. DIAGNOSIS
Right elbow dislocation (posterior)
Close reduction and posterior long arm slab
MANAGEMENT

11. FILM POST-REDUCTION

12. DIAGNOSIS
Right complex elbow dislocation with radial neck fracture
-Stable at 0º
-Further investigation : NECT right elbow
The study reveals fracture right radia neck. Re-location of
the elbow joint. No difinite facture of right humerus and ulna is
seen. No suspicious lytic or blastic lesion

13. ELBOW DISLOCATION
• most common second to the shoulder dislocation
• posterolateral is the most common type of dislocation (80%)

14. MECHANISM OF POSTEROLATEREL DISLOCATION
• usually a combination of axial loading, supination/external
rotation of the forearm, valgus posterolateral force
• a varus posteromedial mechanism (combined with axial load and
forearm external rotation) has also been reported
• posterior dislocations may involve more than one injury
mechanism

15. ANATOMY
Static and dynamic stabilizers confer stability to the elbow
• static stabilizers (primary) : ulnohumeral joint, anterior bundle of the
MCL, LCL complex (includes the LUCL)
• static stabilizers (secondary) : radiocapitellar joint, joint capsule, origins
of the common flexor and extensor tendons
• dynamic stabilizers : muscles that cross the elbow joint, which apply
compressive (stabilizing) force anconeus, brachialis, triceps

16. CLASSIFICATION
Simple vs complex
simple
 elbow dislocation with no associated fracture
 accounts for 50-60% of elbow dislocations

17. CLASSIFICATION
Simple vs complex
complex : elbow dislocation with associated fracture
 may take form of
- terrible triad injury : associated with a LUCL tear, radial head fracture,
and coronoid tip fracture
- varus posteromedial rotatory instability : associated with an LCL tear
and a coronoid fracture

18. PRESENTATION
• Symptoms
pain and swelling
• Physical exam
important to assess the status of the skin - evaluate for open injuries
presence of compartment syndrome, neurovascular status, status of wrist
and shoulder

19. TREATMENT
1. Nonoperative
closed reduction and splinting at least 90° for 5-10 days, early therapy
indications
acute simple stable dislocations
recurrent instability after simple dislocations is rare (<1-2% of
dislocations)

20. TREATMENT
2. Operative
2.1 ORIF (coronoid, radial head, olecranon), LCL repair, +/- MCL repair
indications
acute complex elbow dislocations
persistent instability after reduction
elbow requires >50-60° to maintain reduction
reduction cannot be performed closed often due to entrapped soft tissue
or osteochondral fragments

21. TREATMENT
2. Operative
2.2 open reduction, capsular release, and dynamic hinged elbow fixator
indications
chronic dislocations
Postoperative : hinged external fixator indicated in chronic dislocation to
protect the reconstruction and allow early range of motion

22. TREATMENT
Rehabilitation
Initial
 immobilize for 5-10 days (>3 weeks results in poor ROM outcomes)
early
 supervised (therapist) active and active assist ROM exercises within stable arc
 extension block brace is used for 3-4 weeks
 proceed with light duty use 2 weeks from injury
late rehabilitation
 extension block is decreased such that by 6-8 weeks after the injury full stable
extension is achieved

23. NONOPERATIVE TECHNIQUE
1. inline traction to improve coronal displacement
2. forearm supination to shift the coronoid under the trochlea
3. elbow flexion while placing direct pressure on tip of olecranon

24. COMPLICATIONS
• Early stiffness
• Varus Posteromedial instability
• Neurovascular injuries
• Compartment syndrome
• Damage to articular surface
• Recurrent instability
• Heterotopic ossification
• Contracture/stiffness