Extern conference นิธิรุจน์ 29 มิ.ย. 61

1. NOON
CONFERENCE
Ext.นิธิรุจน์ กิตติธีระพัฒน์
คณะแพทยศาสตร ์โรงพยาบาล
รามาธิบดี
29 มิถุนายน 2561

2. Case
ผู้ป่วยชายไทยอายุ 41 ปี
Cause of injury : Ground level falls
Date of occurrence : 24/6/61 เวลา 22:00 น.
Arriving MNRH : 25/6/61 เวลา 15:00 น.

3. Primary survey
A : Can talk, C-spine not tender, Can flex neck
B : Normal breath sound equal both lungs, No open chest
wound, Chest compression test negative, No distant heart
sound
C : BP 124/80 mmHg, PR 94 bpm
D : E4V5M6, Pupil 3 mm RTLBE, deformity and tenderness at
left shoulder
E : No external bleeding, abrasion wound at left face

4. Secondary survey
A : No drugs or food allergy
M : No current medication
P : No known underlying disease
L : 25/6/61เวลา13:00 น.
E : 1วันก่อนมาโรงพยาบาลผู้ป่วยล้มเอาใบหน้าข้างขวา และไหล่ข้างซ้ายล้ม
กระแทกพื้น ขณะเดินกลับบ้านจากการดื่มสุรา สลบ จาเหตุการณ์หลังจากล้ม
ไม่ได้ ต่อมาตอนเช้าเพื่อนบ้านมาพบ หลังได้สติมีอาการปวดบริเวณหัวไหล่ข้าง
ซ ้าย ยกแขนซ้ายไม่ได้ มีอาการตาพร่ามัวข้างขวา ไม่มีปวดศีรษะ ไม่มีคลื่นไส้
อาเจียน ไม่มีแขนขาชาหรืออ่อนแรง

5. Physical examination
GA : A Thai male alert well cooperation
HEENT : Not pale, anicteric sclerae, Right corneal abrasion
Lungs : clear equal both lungs CCT negative
Heart : normal s1s2 no murmur
Abdomen : soft not tender, PCT negative
Neurological : E4V5M6, full EOM, pupils 2 mm RTLBE, motor
power grade V all extremities, no sensation loss

6. Physical examination
Extremities: limit ROM of left shoulder due to pain, deformity
with tenderness at left shoulder

7. Film both clavicles

9. Problem lists
Mild head injury (moderate risk)
Left acromioclavicular joint dislocation type III
Right corneal abrasion

11. Anatomy

12. Definition
Injuries to the acromioclavicular (AC) joint with soft tissue
disruptions.

13. Mechanism of injury
Direct force to acromion with the
shoulder adducted, usually result
of fall
Acromion moves inferiorly and
medially while clavicle is
stabilized by SC joint ligaments
Chronic overuse

14. Anatomy

15. Signs and symptoms
Injury is most common secondary from traumatic event,
deformity is a common finding and complaint
Distraction between the CC space and AC joint
The examination should be compared with uninjured shoulder.
Cross arm adduction test

16. Signs and symptoms
O’Brien active compression test
with localized pain over AC joint
Paxinos test ( thumb pressure to
the posterior AC joint )
Pain relief after analgesic injection

17. Imaging
Bilateral anteroposterior (AP) view of AC joint
 for compare displacement to the contralateral side
Axillary lateral view
 for diagnose type IV
Zanca view
 10 degree cephalad tilt

18. Differential diagnosis
Base of coracoid fracture
Distal clavicle fracture Neer type 2A

19. Classification
Tossy-Rockwood AC joint dislocation classification
Type I – VI

20. Classification
Type I : mild force to the point of the shoulder
 minor strain to the AC ligament
 ligament remain intact and stable

21. Classification
Type II : moderate force to the point of the shoulder
 severe enough to rupture the AC ligament
 unstable distal clavicle in horizontal plane
 intact CC ligament
 relative slightly upward due to stretching of CC
ligament

22. Classification
Type III : severe force to the point of the shoulder
 complete AC dislocation
 distal clavicle appears to be displaced superiorly
 25-100% increase in CC space comparison to
normal side
 relative slightly upward due to stretching of CC
ligament

23. 15.8 mm
27.5 mm
74%

24. Classification
Type IV : posterior dislocation of the distal end clavicle
 relatively rare
 displace posteriorly into or through the trapezius
muscle as the force applied anteroinferiorly

25. Classification
Type V : markedly more sever of type III
 The distal clavicle has been stripped of all its soft
tissue attachment ( AC, CC, deltotrapezial muscles)
 marked increase of CC distance > 100%

26. Classification
Type VI : Inferior dislocation of distal clavicle
 very rare
 severe hyperabduction, external rotation, retraction
of scapula
 either a subacromial or subcoracoid location

27. Treatment
Non operative treatment
 Brief arm sling, rest, ice, physical therapy
 indicate in type I,II and some of type III with clavicle
displaced < 2 cm
 Rehabilitation : early shoulder range of motion,
regain functional motion in 6 weeks and
return to normal activity in 12 weeks
 Corticosteroid injection maybe considered
 Complication : Arthritis, chronic subluxation & instability

28. Treatment
Operative treatment
 ORIF with ligament reconstruction
 indicate in type IV, V, VI and some of type III in
laborers, athletes, patients with cosmetic concerns or
failed non operative patient
 Contraindication : Skin problems over approach side or
Poor compliance of post operative rehabilitation patient
 Rehabilitation : sling immobilization for 6 weeks, no shoulder
range of motion, return to full activity after 6 months
 Complication : Arthritis, hardware failure, Coracoid fracture

29. Thank you