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Extern case conferenceTHANYAPORN WISITPHORNANAN 5402064
case
Patient profile ผปวยชายไทย อาย 15 ป
Chief complaint ถกหนเจยบาดเทาซาย 7 ชม.กอนมาโรง
พยาบาล
Present illness
7 ชม. กอนมาโรงพยาบาล ขณะทำางาน ถกหน เจยหลนใสเทา บาดนวชเทาขางซายเปนแผล
ลก มอาการชา ปวด ขยบนวชเทาไมได ไมมบาดแผลบรเวณอน
Past History
No underlying disease No current medicationNo drug allergy
Physical examination
ABCD – OK GA – A Thai man , Alert , good consciousness , well
co-operative V/S – Temp 36.7 HR 67 bpm BP 131/87 RR 16 /min
HEENT – not pale conjunctivae , anicteric sclerae Lung – clear , equal breath sound both lungs Heart – normal s1 s2 , no murmur
Physical examination
Laceration wound 0.5 x 2 cm.Deep to bone No active bleedingCapillary refill < 2 secLimit ROM
Film
Left foot AP
Film
Left foot Oblique
middle phalanx of 2nd toe of Left foot fracture
Impression
Open Fracture middle phalanx of 2nd toe of Left foot
R/O tear tendon
Toe Fracture
Anatomy
Management of Toe fracture
First toe• role in weight bearing, balance, and pedal
motion• require referral much more often than other
toe fractures
Lessor toe
Lessor toe fracture Treatment
‘Buddy taping’ 3 weeksPain control Acute subungual hematoma
decompression เจาะเลบ release pressure
Lessor toe fracture
referral is recommended for patients with open fractures, fracture-dislocations displaced intra-articular fractures, children with fractures involving the physis, except nondisplaced Salter-Harris type I and type II
Open Fracture
Gustilo Classification
Management
initial trauma survey and resuscitation IV antibiotics tetanus prophylaxis Dressing - remove gross debris , irrigation Immobilization Set OR for Aggressive debridement and irrigation
Antibiotic Treatment
Gustilo Type I and II 1st generation cephalosporin for gram positive
Gustilo Type III 1st generation cephalosporin for gram positive Aminoglycoside (such as gentamicin) for gram negative +- Penicillin for anaerobe in farm injuries or possible
bowel contamination
Management in this patient
NPO , 5%DN/2 1000 ml iv 80 ml/h Cefazolin 1 g iv q 6 h Tetanus toxoid 1 course Irrigation , dressing wound Immobilization MO 4 mg iv Set OR
Operation
Finding
• Open fracture middle phalanx of left 2nd toe
• Partial tear EDL tendon of left 2nd toe
Operation
Excision debridement with K-wire fixation with tendon repair