Interesting case orthopedic วุฒิกร^^

1. Interesting Case Orthopedic
Extern. Vutthikorn Khingmontri (PCM)

2. CASE ผู้ป่วยเด็กชายไทยอายุ 9 ปี
HN 108-77-97
• Chief complaint : ปวดบริเวณแขนซ้าย 2 ชม PTA
• Present illness :
2 ชม PTA ผู้ป่วยตกต้นไม้ ความสูงประมาณ 2 เมตร มีแขนซ้ายกระแทกพื้น และหัวเข้าซ้ายกระแทกพื้น มี
อาการปวดบริเวณข้อมือซ้าย และมีข้อมือซ้ายผิดรูป ไม่มีบาดแผลตามตัว ไม่มีศีรษะกระแทก จาเหตุการณ์ได้ ไม่
สลบ

3. Primary survey
• A : Patent airway, no stridor, and no posterior cervical tenderness
• B : Equal chest expansion , trachea in midline, equal breath sound ,
both lungs clear
• C : Vital signs (BT = 37 c, PR =100 bpm, BP =120/70 mmHg, RR
=22/min), no external bleeding, no pelvic tenderness or
ecchymosis, abdominal soft not tender
• D : E4V5M6 , pupils 3 mm RTLBE
• E : Deformity at Left wrist, moderate tender, swelling at Left wrist,
PR: normal sphincter tone, yellow feces

4. Secondary survey
• A : no medical allergy
• M: No current medication usage
• P : U/D asthma
• L : Last meal = 19.45
• E : As present illness

5. Head to Toe Evaluation
• Vital sign: BT = 37 c, PR =100 bpm, BP =120/70 mmHg, RR
=22/min, BW= 44 Kg
• GA: Good consciousness, not pale
• HEENT : Not pale conjunctivae , anicteric sclerae , no
subconjunctivae hemorrhage, no evidence of head trauma, no
contusion
• Lungs : Equal chest expansion , equal breath sound , no accessory
muscle use , both lungs clear
• CVS : JVP not engorged , Pulse full and regular , Capillary refill < 2
sec , normal S1S2, no murmur

6. • Abdomen : No distention , soft , not tender , normoactive bowel
sound, no rigidity , no guarding , no rebound
• Extremities : tender at Left wrist, deformity at Left wrist, swelling ,
neurovascular intact, limit ROM due to pain
• Neuro : Good consciousness, well cooperative, good orientation to
time place person
• Motor : Grade V all extremities(except Left forearm due to pain)
• Sensory : Normal sensation to pain , temp and fine touch
Head to Toe Evaluation

8. Investigation: Film X-ray
• Film X-ray Left wrist AP

10. • Green stick fracture distal ulna with dorsal angulation
• Epiphyseal plate injury at distal end radius
• Dx: Closed fracture distal both bone forearm with epiphyseal plate
injury(Salter and Harris type 1)
Investigation: Film X-ray

11. Fracture in children
• Greenstick fracture
• Torus/Buckled fracture
• Plastic deformation

13. Distal forearm fractures in children
• Torus fracture
• Greenstick fracture
• Complete fracture

15. Epiphyseal plate or growth plate
injuries
• Salter-Harris classification

16. Most common

17. Anatomy epiphyseal plate

18. Salter-Harris type 1

19. Salter-Harris type 2 Thurston Holland’s sign

20. Salter-Harris type 3

21. Salter-Harris type 4

22. Salter-Harris type 5
Not clearly seen in x-ray

23. Treatment
Depends on
• Type of injury
• Age of patient
• Fracture stability

24. For type 1 & 2
• Closed reduction and immobilization in cast /splint/slab
• Immobilization for 3-6 weeks
• Check x-ray in7-10 days
Treatment

25. For type 3 & 4(intraarticular)
• Require anatomical realignment
• Closed or opened reduction
• ORIF with lag screws or kirschner wires running parallel to physis
• Immobilization 4-8 weeks
Treatment

26. For type 5
• Usually diagnosis retrospectively
• Gentle reduction
• Closed observation
• Surgical correction
Treatment

27. Complication
• Growth arrest(may be delayed for 2 years)(Most common
in type 4 & 5)
• Complete arrest: Length discrepancy
• Partial arrest: Angulation
• Growth acceleration
• Secondary osteoarthritis

28. Indication for surgery in pediatric
fracture
• Failed closed reduction
• Displace intraarticular fracture
• Displaced epiphyseal plate injury Salter-Harris type 3,4
• Children with multiple fracture or head injury

29. Management
4R
• Recognition
• Reduction
• Retention
• Rehabilitation

30. Management
• Pain control: pethidine 4 mg IV stat
• Closed reduction with long arm AP slab

31. Traction
Increase deformity
Reverse mechanism
Immobilization

32. Three
point

34. Conclusion
• Physeal injuries may not be readily obvious in children presenting
with periarticular trauma
• Treatment and follow up is essence to forestall future complication

35. Reference
• Rock wood and Wilkins fracture in children: Physeal injuries and
growth disturbance: E. Rathjen and Harry K.W. Kim
• Orthopedic trauma.ธีรชัย อภิวรรธกุล