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Externconference sirakit
- 2. Case • ผู้ป่วยหญิงอายุ 59 ปี อาชีพแม่บ้าน • สัญชาติไทย เชื้อชาติไทย ศาสนาพุทธ • Chief complaint : ปวดข้อมือซ้าย 4 ชั่วโมงก่อนมารพ. • Present illness : 4 ชม. ก่อนมารพ. ผู้ป่วยสะดุดล้มใช้มือซ้ายยันพื้นขณะล้ม ไม่สลบ จา เหตุการณ์ได้ จากนั้นมีอาการปวดบวมที่ข้อมือซ้าย กระดกข้อมือไม่ได้ ไม่ชา ไม่อ่อนแรง จงงมารพ. 2
- 3. Primary Survey • A : able to talk, not tender along C-spine • B : Trachea in midline, spontaneous breathing, equal and clear breath sound both lungs, no subcutaneous emphysema • C : BP 154/75 mmHg, PR 99 bpm, no external bleeding • D : E4V5M6, Pupil 3 mm RTLBE • E : Tender and swelling at radial side of left wrist, Limit ROM of left wrist due to pain, full ROM of finger,elbow and shoulder, cap refill < 2 sec, Radial artery 2+, Left fingers full ROM 3
- 4. Secondary Survey • A : ปฏิเสธประวัติแพ้ยา แพ้อาหาร • M : รับประทานยาลดความดันโลหิตสูง • P : no known u/d , no history of surgery • L : Last meal 12.00 • E :สะดุดล้มใช้มือซ้ายยันพื้น ไม่สลบ จาเหตุการณ์ได้ เจ็บบริเวณข้อมือซ้าย ไม่มีส่วนอื่นกระแทก 4
- 5. Physical Examination• GA : Good consciousness • HEENT : Not pale conjunctivae, no facial deformity, full ROM of neck, not tender along c-spine • Heart : Pulse full and regular, Normal S1S2, No murmur • Lungs: trachea in midline, equal chest movement, equal and clear breath sound both lungs • Abdomen, No distension, Soft, Not tender • Extremities : Tender and swelling at radial side of left wrist, Limit ROM of left wrist due to pain, full ROM of finger,elbow and shoulder, cap refill < 2 sec, Radial artery 2+, Pinprick sensation intact, Left fingers full ROM • Neurological exam: E4V5M6, Pupil 3 mm RTLBE, Motor grade V all 5
- 6. Investigation • Film Left wrist AP, Lateral 6
- 7. Film Left wrist AP,Lateral 7
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- 10. Diagnosis • Left distal end radius fracture with Left ulnar styloid fracture 10
- 11. Management • Sedation : MO 5 mg IV stat • Close reduction with Long arm AP slab 11
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- 14. Distal end radius fracture • Approximately 17.5% of all fractures treated by orthopedic surgeons • Three main peaks of fracture distribution: - Children age 5-14 - Males under age 50 (High velocity) - Females over the age of 50 years (Low velocity) • Elderly (Mostly extra-articular) • Young (Mostly intra-articular) • Elderly patient risk factors : Osteoporosis(Decreased bone mineral density), female gender and early menopause 14
- 15. Anatomy • Scaphoid and lunate fossa - Ridge normally exists between these two • Sigmoid notch - Second important articular surface • Triangular fibrocartilage complex (TFCC) - Distal edge of radial to base of ulnar styloid • Interosseous Ligament - scapholunate and lunatriquetral ligament 15
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- 17. Assessment&Diagnosis • History of mechanism of injury • A visible deformity of the wrist is usually noted, with the hand most commonly displaces in the dorsal direction. • Movement of the hand and wrist are painful • Adequate and accurate assessment of the neurovascular status of the hand Is imperative. (Median nerve involvement – Carpal tunnel syndrome) 17
- 18. Assessment&Diagnosis • Evaluation of the injured joint, and a joint above and below (ipsilateral elbow and shoulder joint) • Radiographs of the injured wrist (PA & Lateral) • Radiographs of other areas, if symptoms warrant 18
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- 21. Classification • Gartland & Werley • Older • Frykman • Melone • OA/OTA • Fernandez (mechanism) 21
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- 26. Indication for Non-operative treatment • Low-energy fracture • Low-demand patient • Medical co-morbidities • Minimal displacement-acceptable alignment 26
- 27. 27 • Apply well-molded splint or cast, with wrist in neutral to slight flexion • Check X-ray to confirm the acceptable reduction • Follow up x-rays needed in 1-2weeks to evaluate reduction • Change to short arm cast after 2-3 weeks, continue until fracture healing.
- 28. Indication for Operative treatment • Unstable • Fernandez type II, IV, V and some case in I, III • Lafontaine criteria >3 of 5 instability parameters • Dorsal angulation >20 degree • Dorsal comminuted • Intra-articular radiocarpal fracture • Ulnar fracture • Age >60 • Secondary displacement after casting 28
- 29. Indication for Operative treatment • Irreducible fracture • Double die punch • Displaced comminuted fragment • Articular step off > 2mm • Severe comminution • Shortening > 5mm 29
- 30. Indication for Operative treatment • Unacceptable alignment • Radial inclination < 15 degree • Shortening > 5 mm • Dorsal tilt > 10 degree • Volar tilt > 20 degree • Articular step off or gap >2mm • Open fracture 30
- 31. Indication for Operative treatment • Associated injury • Median Nerve Compression • Distal Radioulnar Joint injury • Carpal Ligament disruption • Partial or complete tear scapholunate ligament • Lunotriquetral ligaments tears 31
- 32. Thanks! 32