PowerPoint

Othopedics ConferenceExt.Nisachon Tongtip2/10/59

CaseA Thai boy 13 years Cause of injury : Motorcycle accidentMechanism : Blunt injury

A : Patient can speak, patent airway, tender along C-spineB : CCT negative, equal breath sound C : BP 80/64, PR112, no active external hemorrhage D : E4V5M6, pupil 3 mm RTLBEE : Abrasion wound at RUQ, deformities both middle arm, no open wound Primary survey at .

Adjunct to Primary survey MonitorCatheterInvestigationsVital signFoley cathFAST + at hepatorenal pouchSpO2NG tubeFilm : Chest, Pelvis, lat. cross-table C-spine

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Initial management base on problemA : on Hard collarB : O2 mask with bag 10 LPM keep SpO2 95%C : RLS IV loading 2,000 mlBP 100/60, PR100 E : NPORetain foley catheter keep urine output 0.5-1 ml/kg/hrRetain NG tube

DiagnosisBlunt abdominal injury with hypovolemic shockCFx both humerus Suspected C-spine injury

Refer

A : Patient can speak, patent airway, tender along C-spineB : CCT negative, equal breath sound C : BP 123/51, PR92, no active external hemorrhage D : E4V5M6, pupil 3 mm RTLBEE : Abrasion wound at RUQ, deformities both middle arm, no open wound Primary survey at MNRH

Adjunct to Primary survey MonitorCatheterInvestigationsVital signFoley cathFAST+ at hepatorenal pouchSpO2NG tubeFilm : Chest, Pelvis, lat. cross-table C-spineHct stat 38%

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Initial management base on problemA : on Hard collarB : O2 mask with bag 12 LPM keep SpO2 95%C : RLS IV 120 ml/hrE : NPORetain foley catheter keep urine output 0.5-1 ml/kg/hrRetain NG tubeCefazolin 1 g IV q 6 hr

A : No drugs allergyM : No current medicationP : No underlying diseaseL : 18.30 21/10/2559E : RoadSecondary survey : History

Head & maxillofacial : swelling at both cheek, mild tender at both zygomatic archCervical spine and Neck : No wound at neck , tender along C-spineChest : CCT negative, equal breath sound, trachea in midlineAbdomen&pelvis : Abrasion wound at RUQ, soft, mild tender at RUQ, PCT negative

Secondary survey : Complete physical exam

Perineum : no wound, no ecchymosis, no hematoma, no urethral bloodPR : Good sphincter tone , no bloodNeurologic : E4V5M6, pupil 3 mm RTLBE

Secondary survey : Complete physical exam

Ortho examinationDeformities both middle arm, swelling, no open woundMotor : cant extensor both wrists, cant extensor all fingerSensory : decrease pinprick sensation at dorsal surface of thumb and index bothVascular : full radial pulses both

Secondary survey : Complete physical exam

Definite diagnosis CFx both humerus with radial nerve palsy Liver injury grade I CFx Lt. zygoma CFx bilat. Maxillary sinus

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Treatment U-slab both arm

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Treatment Surgery : ORIF with P&S both humerus

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Shaft of humerus

Supracondylar ridge

Associated injury Radial nerve injury Brachial artery injury Ulnar & medial nerve injury (less commom)***Neurovascular exam is critical***

Radial nerve test

MotorExtensor muscle of arm & forearmWrist dropThump abductionSensoryPosterior surface of arm&forearmDorsal surface of the lat. three and a half finger

Fracture line

classificationsTransverseObliqueSpiralSegmentWedge

classificationsAO

Holstein-Lewis fracture A spiral fracture of the distal one-third of the humeral shaft 22% incidence associated with neuropraxia of the radial nerve

TreatmentGoal : union with acceptable alignment

Operative treatment

Indication for surgeryAbsoluteRelative

Coaptation splint (U slab) Criteria for acceptable alignment include: < 20 anterior angulation< 30 varus/valgus angulation< 3 cm shortening Outcomes90% union rate increased risk with proximal third oblique or spiral fracture varus angulation is common but rarely has functional or cosmetic sequelae

Radial nerve palsyIncidence 8-15% of closed fractures incidence distal one-third fractures Neuropraxia most common injury in closed fractures and neurotomesis in open fractures 85-90% of improve with observation over 3 months Spontaneous recovery found at an average of 7 weeks, with full recovery at an average of 6 months

TreatmentSurgical explorationIndications Open fracture with radial nerve palsy (likely neurotomesis injury to the radial nerve) Closed fracture that fails to improve over ~ 3-6 months Fibrillations (denervation) seen at 3-4 months on EMG

Radial nerve palsy after reduction is due to nerve entrapment Refer