Ortho conf

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Externconferenceext. anyamanee

Patient profile

4 6 cc: 5 .PI: 5 . . .

Physical examinationA : patent airway, can flex neck, B : rr 22/min, equal chest movement, lung clear, cct negC : BP 100/60 mmhg, HR 109/minD : E4V5M6, pupils 3 mm in diameter react to light both eyesE : deformity left elbow, abrasion wound size 1*3 cm at left arm with ecchymosis size 3*3 cm

Past historyNo underlyingNo history of bone fracture No history of operationNo history of drug allergyNo premedicationLast meal 15.30 pm

Physical examinationHEAD: no external woundMaxillofacial&orofacial: can open mouth, no external wound or contusion at face, no theeth lossCervical spine & neck : not tender along c-spine, can flex neckChest : lungs clear and equal breath sound, no adventitious sound, no stepping at chest wall and not tender, no external wound and contusion at chestAbdomen : soft, not distend, not tender, no external wound or contusionNeurological : Alert, motor power grade V at Rt upper limb, both lower limb

Physical examination

Extremities : left armDeformity Ecchymosis & Abrasion woundSwellingTenderness & Pain on motion Limit ROM of elbowExtremities : left handRadial & ulnar pulse can palpableThumb extensionThumb palmar abductionThumb adductionFinger adductionNormal sensation

DiagnosisSupracondylar fracture of left humerus

Early treatment at ERLong arm a-p slabPethidine 19 mg iv for pain control

Definitive TreatmentSurgery : Close pinningOn posterior slab 4 wkObserve compartment syndrome and neurovascular injury

Supracodylar Fracture

Distal humerus Anatomy

DefinitionFracture that involve lower end of humerus usally involving the thin portion of the humerus through olecranon fossa or just above the fossa or metaphysis

Mechanism of injury

fall on outstretched hand(Extension type)

Mechanism of injury

Fall Directly on the elbow(Flexion type)

ClassificationGartland Classificaiton

Associated injuriesNeuraplexiaanterior interosseous nerve neurapraxia(branch of median n.)the most common nerve palsy seen with supracondylar humerus fracturesradial nerve palsysecond most common neurapraxia (close second)ulnar nerve palsyseen with flexion-type injury patterns

Associated injuries2.Vascular injury 3.Compartment syndrome

PresentationSymptomspainrefusal to move the elbowPhysical examinspectiongross deformityswellingbruisingmotionlimited active elbow motion

Presentation: nerve examAIN neurapraxia unable to flex the interphalangeal joint of his thumb and the distal interphalangeal joint of his index finger (can't make A-OK sign)radial nerve neurapraxiainability to extend wrist or digits may be present due to radial nerve injury neurapraxia

Presentation vascular exam vascular insufficiency at presentation is present in 5 -17%defined as cold, pale, and pulseless hand

Compartment syndrome Extend finger

ImagingAP and lateral x-ray of the elbow

Measurement Imagingdisplacement of the anterior humeral lineanterior humeral line should intersect the middle third of the capitellum capitellum moves posteriorly to this reference line in extension type fracture

Measurement ImagingAlteration 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 degrees, but best judge is a comparison of the contralateral sidedeviation of more than 5 degrees indicates coronal plane deformity and should not be accepted

TreatmentType 1Long arm slab 3 weeks Type 2close reduction then on long arm slab3-4 weeks (elbow flexion 60-90 degree)Type 3Surgery percutaneous pinning ORIF with k-wire

ComplicationPin migrationmost common complication (~2%)Infectionoccurs in 1-2.4%typically superficial and treated with oral antibioticsCubitus valguscaused by fracture malunioncan lead totardy ulnar nerve palsyCubitus varus(gunstock deformity)caused by fracture malunion usually acosmetic issuewith little functional limitations

ComplicationVascular Injurypulseless hand after closed reduction and pinning (3-4%) Volkmann ischemic contractureincrease in forearm compartment pressures and loss of radial pulse with elbow flexed greater than 90Postoperative Stiffness