Orthopedic case teleconferenceExt. Patchara Pornsopanakorn Maharat Nakhonratchasima Hospital

@ERผูป่้วยชายไทยอายุ 42 ปี อาชพีรบัจา้ง ภูมลิ าเนา จ.นครราชสมีา

Chief complaint : เจบ็ไหลซ่า้ย 1 ช ัว่โมง PTA

@ERผูป่้วยชายไทยอายุ 42 ปี อาชพีรบัจา้ง ภูมลิ าเนา จ.นครราชสมีา

Chief complaint : เจ็บไหลซ่า้ย 1 ชัว่โมง PTA

Present illness : 1 hr. PTA ขณะยกกระเบื้องส่งใหเ้พือ่นขึ้นกระบะ ไดย้นิเสยีงกกึบรเิวณไหล ่หลงัจาก

นัน้รูส้กึเจบ็ไหลซ่า้ย ยกขึ้นไมไ่หว ไมม่ปีวดบรเิวณอื่นๆ ไมม่ลีม้หวักระแทก ไมเ่คย

มปีระวตัไิหลห่ลุดมาก่อน ปฏเิสธประวตัดิืม่สุรา

PRIMARY SURVEY

A : can speak, C-spine not tender

B : equal breat sound, CCT negative

C : BP 118/59 mmHg, PR 72 /min

D : E4V5M6, pupil 2 mm RTLBE

E : deformity at Lt. shoulder, tender, mild swelling, no external wound

SECONDARY SURVEY

• Allergy : no food/drug allergy

• Medication : none

• Past history : no U/D

• Last meal : 4 hrPTA

• Event : as in present illness

Physical examination

Ref : http://www.rhpphysiotherapy.com.au/blog/1343/

Physical examination

• GA : A Thai male, fully alert, well co-operative

• V/S : BT 37.1 C, BP 118/59 mmHg, PR 72 /min, RR 18 /min

• HEENT : no pale conjunctivae, anicteric sclerae

• Skin : no external wound seen

• Heart : normal S1 S2, no murmur

• Lung : clear, equal breath sound both lungs

• Abdomen : soft, not tender, normoactive bowel sound

Physical examination

• Extremities : deformity and tenderness at left

shoulder, arm in abduction and external rotation while resting, humeral head can palpate at

anterior of shoulder, limit ROM due to pain, ruler sign +, duga sign -, cap. Refill 2s

• Neuro : motor power gr. V all extremities, sensory intact, reflex 2+ all

Film

DiagnosisAnterior shoulder dislocation

with greater tuberosity fracture

Shoulder Dislocations• Definition : head of humerus loses its articulation with

the glenoid cavity of the scapula

• Classification

Anterior dislocation (98 percents)

Posterior dislocation (2 percents)

Inferior dislocation (very rare)

Anterior shoulder dislocation

• Mechanism : anteriorly directed force on the arm when the shoulder is abducted , extension and externally rotated

Risk factors

•Young age

•Male sex

•Competitive level of sports

•Contact sports

•Excessive caosular laxity

•Large gleno-humeral bone defects

dwyane wade 25 yr.

Anatomy

Anatomy

Anterior shoulder dislocation• Associated injuries

labral & cartilage injuries

Ex. Bankart lesion – associated with a high recurrence rate of dislocation

fractures & bone defects

Ex. Hill Sachs defect (a divot or flattening of humeral head)

Greater/lessor tuberosity fracture

nerve injuries : Axillary nerve injury (transient neurapraxia)

rotator cuff tears : depend on ages

Sign and symptoms• Pain

• Resting position : slightly abduction and external rotation

• May be palpate head of humerus at deltopectoral groove

• Hamilton ruler sign

• Duga’s sign

• Axillary nerve injuries

• Deltoid weakness

Sign and symptoms

Hamilton ruler sign

• Flatted acromion process to lateral epicondyle

Duga’s sign

Film• AP

• Transcapular Y view

Management• Early reduction (control pain / under GA)

• Interlocking sling

• Film after reduction

• Rehabilitation

Reduction• Hippocrates

• Stimson

• Milch

Reduction• Zero position

Abduction 165 degree, forward flexion 45 degree, medial epicondyle on anterior

Traction on humeral shaft axis

Abduction with flexion

Reduction• Traction and counter traction

Film after reduction

Operative• Failed closed reduction

• Soft tissue interposition

• Greater tuberosity fracture displaces > 1 cm.

Interlocking sling• Age <45 : On interlocking sling 1-3 weeks

• Age >45 : until pain relieve, early ROM exercise

Rehabilitation• Phase 1 (0-7 Days)

Interlocking sling

Isometric exercise, wrist and hand exercises

Avoid positions that could cause re-dislocation 6 weeks

• Phase 2 (1-3 weeks)

ROM movement, mobility exercise

• Phase 3 (3-6 weeks)

isometric or static strengthening exercises

Greater tuberosity fracture

• Fracture proximal humerus

• Neer classification

• Displaced fracture

Displaces > 1 cm

Angulation > 45 degrees

• Tx

Non-displaced : arm sling

Displaced : ORIF with P&S

THANK YOU