Extern Conference

Ext. ศรลกษณ วศนะจนดาแกว วนท 14 ธนวาคม 2559

Patient Profile

• ผปวยหญง อาย 54 ป• ภมลำาเนา อำาเภอพมาย จงหวดนครราชสมา• อาชพ คาขาย

Chief complain

ปวดขาซาย 4 ชวโมง กอนมาโรงพยาบาล

Present illness

4 ชวโมงกอนมาโรงพยาบาล ขบ MC ถกMC ชนทบรเวณดานขางลม ไดรบบาดเจบทขาซาย มขาซายผดรป ไมมแผลฉกขาด หลงลมไมสามารถยนหรอเดนได ไมสามารถงอเขาซายได ปวดทขาซายมาก ไมชา ไมมประวตสลบ จำาเหตการณได ผพบเหตการณโทรแจงรถกภย นำาสงโรงพยาบาล

Primary survey

A : Can speak , c-spine not tender, full ROMB : Equal breath sound both lungs, CCT- negC : BP 122/75 mmHg , PR 72 bpm , PCT- neg no active external hemorrhageD : E4V5M6 , Pupil 3 mm RTLBEE : Lt. thigh and Lt. knee swelling ,tenderness, deformity,limit ROM of Lt.knee due to pain,instability

Secondary survey• A : No drugs and food allergy• M : No current medication • P : Unknown underlying disease• L : 16.00 , 12/12/2559• E : ขบ MC ถกMC ชนทบรเวณดานขางลม ไดรบบาด

เจบทขาซาย มขาซายผดรป คกรณไดรบบาดเจบมกระดกแขนหก รกษาทรพช. ไมมผเสยชวตจากเหตการณดงกลาว

Head to Toe examination

• Head and Maxillofacial : – LW 0.5x2 cm at upper eyelid, not tear canaliculi, no

subconjunctival hemorrhage– AW 5x5 cm at Lt.side of face , tenderness,swelling, no stepping

• Cervical spine and Neck : – Not tender at posterior midline of neck

• Chest : – Clear and Equal breath sound both lungs

• Abdomen : – No distension,normoactive bowel sound soft,not tender

• Extremities : as picture

• Inspection:– Lt. knee and Thigh marked swelling ,deformities, ecchymosis at popliteal fossa– Abrasion wound 3x3 cm at posterior of Lt. thigh

• Palpation :– Tenderness at Lt. patellar, along j– Ballotment cannot examine due to pain

• Range of motion :– Limit ROM of Lt.Knee and Lt. Hip

• Neurovascular :– Dorsalis pedis 2+ both side– ABI = 1

Problem lists

• Lt. knee fracture and deformity• R/o vascular injury• Mild head injury ( low risk )• LW at Left upper eye lid

Differential diagnosis

• Fracture Left patella• Fracture Left distal femur• Fracture Left proximal tibia • Left Knee dislocation• Ligament injury

Film Left knee ( AP )

Film Left knee ( lateral )

Diagnosis

• Posterolateral Left Knee dislocation with R/O vascular injury

• Mild head injury ( low risk )• LW at Left upper eye lid

Management

• Initial management At ERConsult trauma R/O vascular injury

- วด ABI = 1 ( ทงกอนและหลง closed reduction)– Closed reduction– On posterior long leg slab– CTA Lower extremities : No evidence of vascular

injury

Knee Dislocation

Anatomy

Epidemiology

• Rare• high-energy : – usually from MVC or fall from height– commonly a dashboard injury resulting in axial

load to flexed knee• Low – energy:– Athletic injury

Associated injuries

Associated injuries

Classification

• based on direction of displacement of the tibia

• Anterior- most common type of dislocation (30-50%)– due to hyperextension injury– usually involves tear of PCL– arterial injury is generally an intimal tear due to traction

• posterior– 2nd most common type (25%)– due to axial load to flexed knee (dashboard injury)– highest rate of complete tear of popliteal artery

Classification

• Lateral - 13% of knee dislocations– due to varus or valgus force– usually involves tears of both ACL and PCL– highest rate of peroneal nerve injury

• Medial– varus or valgus force– usually disrupted PLC and PCL

• Rotational

– posterolateral is most common rotational dislocation– usually irreducible

Classification

Presentation

• Symptoms– history of trauma and deformity of the knee– knee pain & instability

Sign

• appearance• 50% spontaneously reduce before arrival to ED

(therefore underdiagnosed)• swelling, effusion, abrasions• Deformity (do not wait for radiographs, reduce

immediately, especially if absent pulses )• "dimple sign"

Dimple sign

Sign

• vascular exam– palpate the dorsalis pedis and posterior tibial pulses

• if pulses are present and normal – does not indicate absence of arterial injury – measure Ankle-Brachial Index (ABI)

• If pulses are absent or diminished – perform immediate reduction and reassessment– immediate surgical exploration if pulses are still absent following

reduction

ischemia time >8 hours has amputation rates as high as 86%

Imaging• Radiographs – may be normal if spontaneous reduction

• look for asymmetric or irregular joint space

• look for avulsion fxs (Segond sign - lateral tibial condyle avulsion fx)

• osteochondral defects

• MRI – required to evaluate soft tissue injury (ligaments, meniscus)

and for surgical planning – obtain MRI after acute treatment

Managemant• Initial Treatment– reduce knee and re-examine vascular status• considered an orthopedic emergency• splint knee in 20-30 degrees of flexion • confirm reduction is held with repeat radiographs in

brace/splint

• Operative– emergent surgical intervention• indications

– vascular injury repair (takes precedence)– open fx and open dislocation– irreducible dislocation– compartment syndrome

Managemant

Delayed ligamentous reconstruction/repair • indications

– patients can be placed in a knee immobilizer for 6 weeks for initial stabilization

» improved outcomes with early treatment (within 3 weeks)

Managemant

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