Extern orthopedic-conference-prima

Extern orthopedic conference

Ext. Prima Boonveerabut23rd Jan, 2017

Patient profile• ผปวยชายไทย อาย 22 ป• สถานภาพ โสด• ภมลำาเนา อำาเภอคง จงหวดนครราชสมา

• มาโรงพยาบาลมหาราชนครราชสมา วนท 21 มกราคม 2560 เวลา 10.00 น

Chief complaint• ปวดไหลซาย 3 ชวโมงกอนมาโรงพยาบาล

Present illness• 3 ชวโมงกอนมาโรงพยาบาล ผปวยลมจากเตยง

แลวเอามอซายยนพนไว จากนนมอาการปวดไหลซาย รสกไหลซายหลด ยกแขนซายไมได ขยบมอได ปวดไหลซายมากจงมาโรงพยาบาล

Primary survey• A : Can speak, c-spine not tender, full

ROM of neck• B : Equal breath sound, CCT negative• C : BP 142/75 mmHg, PR 105 bpm, no

active external bleeding• D : E4V5M6, pupil 3 mm RTLBE• E : No external wound, deformity and

limit ROM at left shoulder

Secondary survey• A : ปฏเสธประวตแพยาหรอแพอาหาร• M : ปฏเสธยาทใชประจำา• P : ปฏเสธประวตโรคประจำาตว• L : NPO 7.00 น. 21 มกราคม 2560• E : ผปวยลมจากเตยงแลวเอามอซายยนพนไว จากนนม

อาการปวดไหลซาย รสกไหลซายหลด ยกแขนซายไมได ขยบมอได เคยไหลซายหลด 2 ครงในชวง 2 เดอนทผานมา

Physical examination• General appearance : A Thai man, alert,

well co-operative• Vital signs: BP 142/75 mmHg, PR 105

bpm, RR 18 bpm, BT 36.5 ำC• HEENT : Not pale conjunctivae,

anicteric sclera• Heart : Normal S1S2, no

murmur• Lung : Clear both lungs• Abdomen : No distension, soft, not

tender• Neurological : Grossly intact

Physical examinationLeft shoulder • Flatten left deltoid,

deformity, mild swelling, tender, limit ROM all direction

• Duga’s test positive, Ruler test positive

• Neurovascular : intact

Investigation• Film left shoulder AP• Film left shoulder transcapular

Film left shoulder AP

Film left shoulder

transcapular

Diagnosis• Anterior left shoulder dislocation

Management• Pain control with MO 5 mg IV stat• Closed reduction : Traction-

countertraction• On interlocking arm sling• Film left shoulder AP, left shoulder

transcapular หลง closed reduction• Home medication : Paracetamol (500) 1

tab oral prn for pain q 4-6 hr• Follow up 2 weeks

Film left shoulder AP

Film left shoulder

transcapular

Shoulder dislocation

Shoulder (Glenohumeral) dislocation• Most commonly dislocated joint in

the body• Can occur anteriorly (95-97%),

posteriorly (2-4%), inferiorly, or anterior-superiorly

• Previous shoulder dislocation are more prone to redislocation

Tissue does not heal properly and/or tissue stretches out and becomes more lax

Shoulder (Glenohumeral) dislocation• Shoulder stability Glenohumeral ligaments : Inferior

glenohumeral ligament Joint capsule Rotator cuff muscles Negative intra-articular pressure : Suction

cuff effect by capsule & labrum Bony/cartilaginous anatomy

Shoulder (Glenohumeral) dislocation• Patients who tear their rotator cuffs or

fracture the glenoid during their shoulder dislocation have a higher incidence of redislocation

Mechanism of injury• Anterior dislocation abducted, externally

rotated, extended arm eg. Blocking a basketball shot, posterior

force, fall on an outstretched arm• Posterior dislocation adducted,

internally rotated arm eg. Seizure

Radiographic

anatomy

Humerus :

(1) Scapula (Y) : (2) Glenoid

fossa : (3)

Anterior shoulder dislocation : Subtype• Subcoracoid

(90%)• Subglenoid• Subclavicle• Intrathoracic

Clinical presentation & Physical examination Clinical presentation• Pain on affected side• Arm is in slight abduction and external

rotation• Loss of normal of the shoulderPhysical examination• Anterior bulge of head of humerus may

be visible/palpable• Limited ROM• Special test : Dugar’s sign, Ruler’s sign

Associated injury of shoulder dislocation• Stretching/tear of

capsule• Avulsion of

glenohumeral ligament• Labral injury : Bankart

lesion• Impression fracture :

Hill-Sachs lesion• Rotator cuff tear• Injury to axillary nerve

Complication** : Recurrent dislocation

Hill-Sachs lesion

Bankart lesion

ManagementNon-operative• Closed reduction• Film X-ray confirmed after reduction• Immobilization : Interlocking sling• Pain control• Rehabilitation Operative

Closed reduction1. Hippocretes

method2. Traction-

countertraction3. Stimson’s

method4. Milch’s

technique5. Kocher’s

technique

Follow up care• Immobilized in adduction

and internal rotation for 3 week in patient under

30 years old : Risk of redislocation

For 1 week in patient over 30 years old and early mobilization

• Rehabilitation

Operative treatmentIndication• Failed non-operative treatment• Irreducible dislocation• Open dislocation• Recurrent dislocation in young age

THANK YOU