Extern Conference Ortho ext. สิทธิณัฐ

1. Ext.สิทธิณัฐ สุระประเสริฐ

2. Patient Profile
• ผู้ป่วยชายไทย อายุ 51 ปี
• ภูมิลาเนา อ.ขามทะเลสอ จ.นครราชสีมา
• อาชีพ เกษตรกร

3. Chief complaint
• ถูกมีดฟันมือข้างซ้าย 3 ชม. ก่อนมา รพ.

4. Present illness
• 3 ชม.ก่อนมารพ. ผู้ป่วยใช้มีดฟันหลังมือซ้ายตัวเอง ขณะกาลังถาง
หญ้า เป็นแผลเปิดมีเลือดออก ขยับนิ้วได้น้อยลง ไปรักษาที่รพช.ขาม
ทะเลสอ และถูกส่งตัวมาที่รพ.มหาราชฯ

5. Past history
• No U/D
• No current medication
• มีประวัติแพ้ยาชุด(ไม่ทราบชนิดยา)

6. Primary survey
• A : airway patent , no midline neck pain
• B : no dyspnea
• C : BP 124/82 , PR 88
• D : E4V5M6, pupil 3 mm RTLBE
• E : laceration wound 3cm at dorsal side of 2nd
MCP joint

7. Secondary Survey
• A : แพ้ยาชุด
• M : no current medication
• P : no U/D
• L : NPO time 5 hr PTA
• E : as in present illness

8. Physical Examination
• Vital sign : T 36.5°c, BP 124/82 , PR 88, RR 20
• GA : A Thai man, alert, good conscious
• Heart & Lung : WNL
• Abdomen : WNL
• Neuro : grossly intact

9. Physical Examination
• Extrimities :
– Laceration wound 3 cm at dorsal side of 2nd MCP
joint
– Loss of active extension of 2nd MCP joint
– Extensor tendon tear was seen
– Capillary refill < 2 sec
– Sensory intact

12. Management
• Local wound exploration under sterile
technique
• Film left hand AP,oblique

14. Impression
• Tear extensor tendon zone V of 2nd finger

15. Management
• Set OR for debridement with repair tendon

17. Anatomy

19. Anatomy of finger

20. Extensor tendon compartments

21. Zones of injury

22. Physical Examination
• Loss of active motion
• Tenodesis effect
• Wound exploration under sterile technique

23. Management
• Extensor tendon repair must be performed for
two goal
– Maximize strength
– Minimize shortening

24. Complication
• Formation of adhesions between the repair
site, adjacent skin and bone

25. Zone I injury
• Mallet finger

26. Mallet finger
• Also known as “baseball finger”
• Mechanism of injury
– Traumatic impaction blow
– Dorsal laceration
• Presentation
– Pain and swelling at DIP joint
– Loss of active extension of DIP joint
– Hyperextension of PIP joint (swan neck deformity)

27. Management
• Non-operative
– Extension splinting of DIP joint for 6-8 weeks is
standard of care
– PIP joint must be maintained free movement

28. Management
• Operative
– K-wire fixation / pull-out wire
– Indication
• Open injury
• Avulsion injury
• Volar subluxation of distal phalanx

29. Zone III injury
• Boutonniere deformity
– rupture of the central slip over PIP joint

30. Boutonniere deformity
• Mechanism of injury
– Laceration
– Traumatic avulsion
• Presentaion
– PIP flexion and DIP extension
– Elson test

31. Management
• Non-operative
– PIP splint full-timed 6 weeks and at night 6 weeks
– DIP & MP must be maintained free movement
• Operative : central band repair
– Indication :
• Open wound
• Avulsion fracture

32. Zone IV injury
• Often associated with a proximal phalanx
fracture
• The fractures should be operatively stabilized
to allow tendon rehabilitation

33. Zone V injury
• Clench fist injury

34. Clench fist injury
• So-called “Human bite injury” or “Fight bite”
• Partial extensor tendon injury caused by a
punch to an opponent’s mouth
• The joint often become contaminated with
oral flora, that can lead to septic joint
• Streptococcus species and Staphylococcus
species is the most frequently cultured
organism

35. Clench fist injury
• The tendon injury is proximal to the skin
• The metacarpal head should be inspected for
a retained tooth or articular damage

36. Management
• First priority is prevention of infection
• Extensor tendon repair can be delayed 7 to 10
days until absence of infection is ensured
• Partial laceration does not need to be repaired
• Treat infection empirically with IV antibiotics
for 48 hours, then adjust regimen based on
culture result

37. Reference
• Green’s operative hand surgery, fifth edition
• ตาราออร์โธปิดิคส์ 1, ภาควิชาศัลยศาสตร์ออร์โธปิดิคส์และ
กายภาพบาบัด คณะแพทยศาสตร์ศิริราชพยาบาล มหาวิทยาลัยมหิดล
• www.orthobullet.com