Ortho pom (1) Ext.ธัญกร 29 มิ.ย. 61

1. EXTERN
CONFERENCE
Ext. Thanyakorn Chirakunakorn
Faculty of medicine,
Ramathibodi hospital
29 June 2018

2. CASE
• หญิงไทยคู่อายุ 59 ปี ภูมิลาเนา จ.นครราชสีมา
• CC : ล้มมือซ้ายกระแทกพื้นมา 1 hr PTA
• Present illness: 1 hr PTA ขณะกาลังพยุงตัวลุกจากแคร่นั่ง ฝนตกจึงเกิดลื่นเสียหลัก
เอามือซ้ายลง มีอาการปวดบวมที่ข้อมือซ้าย มีข้อมือผิดรูป ไม่มีศีรษะกระแทกพื้น ไม่สลบ จา
เหตุการณ์ได้ ไม่ได้รับบาดเจ็บบริเวณอื่น
• No known underlying disease

3. PRIMARY SURVEY
A : Can talk, C-spine not tender, Can flex neck
B : trachea in midline,RR 20 bpm, Normal breath sound equal both
lungs, No open chest wound, Chest compression test negative,
No distant heart sound
C : BP 166/92 mmHg, PR 96 bpm, PCT negative
D : E4V5M6, Pupil 3 mm RTLBE
E : No external bleeding, No external wound, left wrist deformity

4. Dinner fork/ silver fork deformity

5. SECONDARY SURVEY
• Allergy : no food/drug allergy
• Medication : no current medication
• Past history : Tubal ligation 20 years ago
• Last meal : 4 hr PTA
• Event : as in present illness

6. PHYSICAL EXAMINATION
• GA: A Thai elderly woman, well cooperate
• HEENT: Not pale conjunctivae, anicteric sclerae
• CVS: normal s1 s2, no murmur
• Lungs: clear equal both lungs
• Abdomen: soft, not tender
• Neuro: E4V5M6, pupil 3mm RTLBE
• Extremities: Lt.wrist: deformity,marked swelling,tender,redness, crepitation, stepping,
limit ROM,Radial pulse 2+, intact nerve,cap refill<2s

7. LEFT WRIST AP,LAT

8. MANAGEMENT
• Hematoma block
• Close reduction
• On AP short arm slab

9. DIAGNOSIS :
CLOSED FRACTURE AT LEFT DISTAL END RADIUS
FRACTURE (COLLES’ FRACTURE)

10. • Most common fractures of the upper extremity in younger
and older patients.
• Occur through the distal metaphysis of the radius
• May involve articular surface frequently involving the ulnar
styloid
DISTAL END RADIUS FRACTURE

11. ANATOMY

12. • Most commonly a fall on an outstretched
extremity with the wrist in dorsiflexion,
impact loading of distal radius
• Younger patient – high energy
• Older patient – low energy/ fall
• High energy may result in significantly
displaced, highly unstable fracture
• 50 % intra-articular
• High incidence of distal radius fracture in
women >50 years old relate with
osteoporosis
MECHANISM OF INJURY

13. CLINICAL EVALUATION
• Open wound (common occur in ulnar
side)
• gross deformity of the wrist
• swollen
• Tender on palpitation – fracture site
• Limit and painful ROM –> Ipsilateral
shoulder and elbow must be examined
• Neurovascular exam
paresthesia/numbness ->median nerve
for acute carpal tunnel compression
syndrome

14. ASSOCIATED INJURY
• Associated injuries - DRUJ injuries must
be evaluated
• radial styloid fx - indication of higher
energy
• soft tissue injuries in 70%
– TFCC injury (Triangular Fibrocartilage
Complex) 40%
– scapholunate ligament injury 30%
– lunotriquetral ligament injury 15%

15. • 3 view of the wrist including true PA(PA zero), Lateral +/- Oblique
• Oblique view – useful for assess radial comminution, depression of radial styloid
• CT scan is selected in some cases ; Intraarticular fractures with multiple fragments,
centrally impacted fragments, DRUJ incongruity
RADIOGRAPHIC EVALUATION

18. 15
26

19. Dorsal 2

20. RADIOGRAPHIC FINDINGD
• Extra or intra-articular fracture
• Dorsal angulation
• Dorsal tilt
• Dorsal comminution
• Radial shortening
• Ulnar styloid fracture
• ( Ulnar variance )

21. CLASSIFICATION
• Fernandez: based on mechanism of injury**
• Frykman: based on joint involvement (radiocarpal and/or
radioulnar) +/- ulnar styloid fx
• Melone: divides intra-articular fxs into 4 types based on
displacement
• AO: comprehensive but cumbersome
• Eponyms: see table for list of commonly used eponyms

22. Colles Fracture
• Combination of intra and extra articular fractures
of the distal radius with dorsal angulation (apex
volar), dorsal displacement, radial shift, and radial
shortenting
• Most common distal radius fracture caused by fall
on outstretched hand
Smith Fracture (Reverse Colles)
• Fracture with volar angulation (apex dorsal) from a
fall on a flexed wrist
Barton Fracture
• Fracture with dorsal or volar rim displaced with the
hand and carpus
Radial Styloid Fracture (Chauffeur Fracture)
• Avulsion fracture with extrinsic ligaments attached
to the fragment
• Mechanism of injury is compression of the
scaphoid against the styloid

23. Fernandez 1987
unstable
unstable
stable
stable
unstable

24. TREATMENT
• Non-operative
• Operative

25. CLOSED REDUCTION
• Hematoma block 8-10cc of 1% lidocaine without adrenaline in the fracture site
• longitudinal traction + wrist ulnar deviate assistant (manual) or chinese finger trap 5
kg, 5 minutes
• Increase deformity  Reverse mechanism  Reapposition  Decrease deformity
• If still have stepping, try reduction again
• arm cast/ AP slab with three point fixation (short sab/cast prefer for olderly)
• X-ray confirm

26. 1.Unstable type
-Fernandez type II,IV,V and some
cases in I,III
Lafontaine criteria≥3 of 5
instability parameters
-Secondary displacement after
casting
2. Irreducible fracture
3. Unacceptable aligment
4. Open fractures
5. Associated injury
INDICATION FOR SURGERY

27. Unacceptable alignment
• Radial inclination < 15o
• Shortening > 5 mm
• Dosal tilt > 10o
• Volar tilt > 20o
• Articular step off or gap > 2 mm
Irreducible fracture
• Double die punch
• Displaced comminuted PM
fragment
• Articular step > 2 mm
• Severe comminution
• Shortening > 5 mm

29. COMPLICATION
• Compartment syndrome
• Median nerve neuropathy
• Distal radio-ulnar joint instability
• Post-traumatic arthritis
• Malunion

30. ADVICE
- เป็นโรคอะไร ได้รักษาอะไรไปบ้าง จาเป็นต้องผ่าตัด
หรือไม่ ในกรณีไม่ต้องผ่าตัด ต้องใส่เฝือกนานอย่างน้อย 4
สัปดาห์
- ใน 24 ชั่วโมงแรก ถ้ามีอาการแขนบวมมากขึ้น ชามากขึ้น
ขยับได้น้อยลง ให้มาพบแพทย์โดยเร็ว
- เริ่มขยับข้อข้างเคียง เช่น นิ้วมือ ข้อศอก หัวไหล่ กันข้อติด
แข็ง
- หากคัน อาจโรยแป้ง กินยาแก้แพ้ได้ ไม่ควรใช้วัตถุแหย่
เข้าเฝือก
- หากมี osteoporosis ให้รักษาต่อไป

31. TREATMENT GOALS
• Preserve hand and wrist function
• Realign normal osseous anatomy – articular surface
• Promote bony healing
• Allow early finger and elbow ROM
Pain control + follow up clinical and film 1-2 weeks are important

32. Recognition  Life threatening condition
Resuscitation  save life
Re-evaluation  complete systematic evaluation
Reduction
Retention fracture-dislocation
Rehabilitation
Reconstruction
PRINCIPLE OF TRAUMA ORTHOPEDIC
CASES

33. REFERENCE
• Rockwood and Green’s, Fractures in Adults, eighth edition
• https://www.orthobullets.com
• http://www.aopublishing.org/
• http:// plasticsurgerykey.com/management-of-wrist-fractures/

34. THANK YOU