Extern conference Ext.พรปวีณ์ 20 ก.ย. 61

1. Case conference
Extern Pornpavee Siricharoenthai PCM

2. Case
เด็กชายไทย อายุ 3 ปี 9 เดือน
ภูมิลาเนา จ.นครราชสีมา

3. Chief complaint
ปวดแขนขวา 4 ชั่วโมง ก่อนมาโรงพยาบาล

4. Present illness
4 ชั่วโมง PTA ผู้ป่วยปั่นจักรยาน ล้มแขนขวากระแทกพื้น มีอาการปวด
บวมที่ต้นแขนข้างขวา แขนผิดรูป ยกแขนไม่ได้ กามือได้ลาบาก ไม่มีศีรษะ
กระแทก ไม่สลบ ไม่มีบาดแผลภายนอก

5. Past history
ปฏิเสธโรคประจาตัว
ปฏิเสธแพ้ยา แพ้อาหาร
ปฏิเสธประวัติผ่าตัดในอดีต
NPO time 9.30น.(18/9/61)

6. Physical examination
Vital signs: BT 37.1c, PR 94/min, RR 20/min, BP 120/70
mmHg
General appearance: A Thai boy, awake, crying
HEENT: not pale conjunctivae, no icteric sclerae
Heart: normal S1S2, no murmur
Lungs: equal chest expansion, equal breath sound both
lungs, no adventitious sound
Abdomen: no distension, normoactive bowel sound, soft, not
tender

7. Physical examination
Extremities: right arm deformity, marked
swelling right elbow, ecchymosis at right
elbow, limit ROM due to pain, capillary refill
<2 sec, radial pulse 2+
Neuro: WNL

8. Film right elbow AP,
Lateral

10. Diagnosis : close fracture
right supracondylar fracture
grade III

11. Management
Set OR for close reduction with percutaneous
pinning

12. Pre-operative evaluation
CBC: Hb 12.9 g/dl, Hct 38.9 %, Platelet
464000, WBC 22,000 (N 91.3%, L 6.8%)
CXR

14. Pediatric ortho
~ Supracondylar fracture ~

15. Supracondylar fracture of
humerus
Second most common in child
ages 3-8 years old
Mechanism: fall on outstretched hand in
elbow hyperextension (95%)
posterior displacement

17. Presentation
Symptoms
-pain
-refusal to move the elbow

18. Physical exam
Inspection
-Gross deformity
-Swelling
-Ecchymosis in antecubital fossa
Motion
-Limit active elbow motion
Neurovascular exam

19. Neurovascular injury

20. Imaging
Recommended views:
AP and lateral x-ray of the elbow (really of the
distal humerus)

21. Findings
posterior fat pad sign
lucency on a lateral view along the posterior distal humerus and
olecranon fossa is highly suggestive of occult fracture around
the elbow

22. Measurement
displacement of the anterior humeral line
-anterior humeral line should intersect the
middle third of the capitellum in children > 5
years old, and touches the capitellum in
children in children <5.
-capitellum moves posteriorly to this reference
line in extension type fractures and anteriorly in
flexion type fractures

24. Measurement
alteration of Baumann angle
-Baumann's angle is created by drawing a line
parallel to the longitudinal axis of the humeral shaft
and a line along the lateral condylar physis as
viewed on the AP image
-normal is 70-75°
-deviation of >5-10° indicates coronal plane
deformity and should not be accepted

26. Gartland’s classification

27. Gartland’s classification
Type I : the anterior cortex is broken. The posterior cortex
remain intact, and there is no or minimal angulation of distal
fragment

28. Gartland’s classification
Type II : the anterior cortex is fractured and the posterior
cortex remain intact. However, plastic deformation of the
posterior cortex, or “green sticking” allows angulation of the
distal fragment.

29. Gartland’s classification
Type III : the distal fragment is completely displaced
posteriorly.

30. Treatment
Type I : long arm casting
Type II : closed reduction +/- percutaneous
pinning
Type III : closed reduction and percutaneous
pinning
Open reduction in irreducible, open fracture

31. Surgical complication
Cubitus varus: common in posteromedial type
Nerve injury
Joint stiffness
Myositis ossificans

32. Thank You