conference ext.สิทธิกร ปภาวิน orthokorat 1
TRANSCRIPT
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Interesting case
Ext. สทิธกิรปภาวนิ 5402161
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Patient profile เด็กชายไทย อายุ 6 ปี
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Chief Complaint
ตกต้นไทรแขนซา้ยบวมผิดรูป 1 ชม.ก่อนมาโรงพยาบาล
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Intial management Airway with c spine protection Breathing Circulation Disability Exposure and environment control
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Secondary survey ไมแ่พย้าแพอ้าหาร ไมม่โีรคประจำาตัว ไมใ่ชย้าใดเป็นประจำา NPO time 8 ชม.ก่อนมาโรงพยาบาล
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Event 1ชม. ก่อนมาโรงพยาบาลตกจากต้นไทร จากนัน้
ปวดแขนขา้งซา้ยทันที และ แขนซา้ยผิดรูป ไมย่อม ขยบัขอ้ศอกแขนและขอ้มอื ไมส่ลบ ไมม่หีวั
กระแทกพื้น ไมป่วดหวั ไมค่ล่ืนไส้
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Physical Examination (แรกรบั)
V/S- BT 37.4 C, BP 139/55 mmHg, PR 106/min, RR 20/min O2 sat 97% room air
GA- alert Skin:no rash HEENT no wound at face and scalp Heart-normal s1 s2 Lungs-symmetrical chest wall movement,
no use accessory muscle,good air entry,no adventicious sound
Abdomen-no distension, soft,not tender
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extremitiesS shape deformities,swelling,ecchymosis 3 cm,marked tenderness at distal humerus of left arm,loss of isosceles triangle,range of motion limited due to pain,no wound, no fat globue
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S shape deformities
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S shape deformities
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S shape deformities
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neurovascular Radial pulse 2+ Ulnar pulse 2+ Capillary refill < 2 sec OK sign intact Great sign intact Bye-bye sign intact
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Problem list
Acute left elbow pain and deformities
History of trauma at left elbow
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DDx Closed Supracondylar fracture of
left the humerus Closed Lateral condyla fracture of
left the humerus Subluxation of the radial head of left
elbow
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Immobilization Temporary splint(woody splint) or
Long posterior arm slap Go to x-ray
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investigation Flim elbow true AP,Lat
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Preoperative Diagnosis Closed Totally displace
Supracondylar fracture of left the humerus (GARTLAND 3)
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Refer Definitive treatment Close reduction in OR with internal
fixation by K-wire percutaneous crossed pinning
Apply posterior long arm slab in slightly flexion and arm sling
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Postoperative Diagnosis Closed Totally displace
Supracondylar fracture of left the humerus (GARTLAND 4 )
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Post op care Elevation/swelling control Pain control Observe compartment syndrome and
neurovascular complication Remove pin and slab at 4
week/clinical union
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SUPRACONDYLAR FRACTURES OF
HUMERUS
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Distal Humerus Anatomy
Medial epicondyle proximal to trochlea –
Lateral epicondyle proximal to capitellum –
Radial fossa – accommodates margin of radial head during flexion
Coronoid fossa – accepts coronoid process of ulna during flexion
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Supracondylar Fractures of Humerus
It is # which involves the lower end of the humerus usually involving the thin portion of the humerus through
Olecranon fossa orJust above the fossa orMetaphysis
Most common elbow injuries in children.
Makes up approximately 60% of elbow injuries.
Becomes uncommon as the age increases.
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General considerations Incidence of supracondylar #:
a) Age : peak age : 5-7 yrs
Average age : 6.7 yrs
b) Sex : Boys > Girls (Earlier)
Boys = Girls (Latest Trends)
c) Side : Left > Right ( Non dominant >
dominant )d) Nerve injuries : 7% - Median>
Radial > Ulnare) Vascular injuries : 1%f) Open injuries : < 1%
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g) Cause of # Fall from height 70% ----- children > 3 yrsFall from bed children < 3 yrsNon accidental injury ( Child abuse) children < 15
months
h) Associated #s Distal radius > Scaphoid > Proximal
humerus > Monteggia
i) Clinical typesExtension type: 98%Flexion type : 2%
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Mechanism of injury For Extension
type of SC # humerus
Fall on outstretched hand
Elbow hyper extended
Fore arm – pronated or
supinated
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Mechanism of injury
For Flexion type of SC # humerus
Fall directly on the elbow rather than out stretched hand
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Radiographic anatomy of distal Humerus
What are the radiographic views:Antero posteriorLateralObliqueAxial ( jones view )
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What to look for in
AP View----- Baumann`s angle
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Radiographic Anatomy
Baumann’s angle is formed by a line perpendicular to the axis of the humerus, and a line that goes through the superior part of physis of the capitellum.
There is a wide range of normal for this value, and it can vary with rotation of the radiograph.
The Baumann angle is good measurement of any deviation of distal humerus`s angulation
In this case, the medial impaction and varus position alters the Bauman’s angle.
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Radiograph Anatomy/Landmarks
Anterior Humeral Line:
This is drawn along the anterior humeral cortex.
It should pass through the junction of anterior & middle 3rd of the capitellum.
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Radiograph Anatomy/Landmarks
The capitellum is angulated anteriorly about 30 degrees.
The appearance of the distal humerus is similar to a hockey stick.
30
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Radiograph Anatomy/Landmarks
The physis of the capitellum is usually wider posteriorly,
compared to the anterior portion of the physis Wider
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Anatomical classification of SC #
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Radiographic Classification of SC #s
Based on X- Ray appreance # displacement Gartland described 3 types:
Type – I : Undisplaced
Type – II : Displaced (posterior cortex intact)
Type –III : Displaced ( no cortical contact)
Posteromedial Posterolateral
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Type 1: Non-displaced
Note the non- displaced fracture (Red Arrow)
Note the posterior fat pad (Yellow Arrows)
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Type 2: Angulated/Displaced Fracture with Intact Posterior
Cortex
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Type 3: Complete Displacement, with No Contact between
Fragments
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Clinical signs & Symptoms
In most cases, children will not move the elbow if a fracture is present, although this may not be the case for non-displaced fractures.
Swelling about elbow is a constant feature, develop within first few hrs.
S shaped deformity
Distal humeral tenderness
Anterior plucker sign +ve
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S-shaped configuration of UL
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Physical Examination Neurologic exam is essential, as nerve injuries are
common. In most cases, full recovery can be expected
Neuro-motor exam may be limited by the childs ability to cooperate because of age, pain, or fear.
Thumb extension– EPL (radial – PIN branch)
Thumb flexion – FPL (median – AIN branch)
Cross fingers - Adductors (ulnar)
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Nerve injury incidence is high, between 7 and 16 % (median, radial and ulnar nerve)
Anterior interosseous nerve is most commonly injured nerve
In many cases, assessment of nerve integrity is limited , because children can not always cooperate with the exam
Carefully document pre manipulation exam, as post manipulation neurologic deficits can alter decision making
Physical Examination
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Vascular injuries are rare, but pulses should always be assessed before and after reduction
In the absence of a radial and/or ulnar pulse, the fingers may still be well-perfused,
because of the excellent collateral circulation about the elbow
Doppler device can be used for assessment
Physical Examination
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Physical Examination
Thorough documentation of all findings is important. A simple record of “neurovascular status is intact” is unacceptable.
Individual assessment and recording of motor, sensory, and vascular function is essential
Always palpate the arm and forearm for signs of compartment syndrome.
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Treatment General principles:
Splinting elbow in comfortable position
20-30degrees of flexion of elbow, pending
Careful physical examination & X-ray evaluation.
Tight bandaging/ excessive flexion or excessive extension should be avoided
Associated life threatening complications ( if any)
to be attended first.
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Simple posterior long arm splint for 3-7days.
Elbow 60-90o flexion & Forearm neutral position.
Check X-ray after 3-7 days to document any displacement or lack of it.
Splint converted to long arm cast if no displacement.
If displacement noticed # reduction done & cast applied or pinning done.
Treatment of type – I #
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Duration of immobilisation 3-4wks.
No need for any physiotheraphy ( Generally )
Outcome: Predictablly excellent if alignment is maintained during early healing.
Hence type – I #s requires careful
treatment & follow up.
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Treatment of type – II # Good stability obtained after closed reduction.
Once satisfactory reduction achieved further management is same as type – I.
If medial column collapse present then skeletal stabilisation with 2 lateral pins is advocated.
Recent trends led to SELECTIVE PINNING for type – II #s
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SELECTIVE PINNING Closed reduction is done Splinting in flexion Non movable cuff & collar sling Early careful X-ray follow up
If # displacement /angulation noticed pin stabilisation is
done .
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Treatment of type – III # Treatment involves management of
skeletal injuries & associated soft tissue injuries (if any).
Treatment of skeletal injury:Reduction either closed or open Stabilisation either with pins or
cast
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Technique of reduction (closed)
Traction – to restore length & alignment. Milking maneuver -- if length & alignment
not restored by traction
Correction of medial/ lateral displacements. Correction of rotational deformities. Correction of posterior displacement by --
flexion reduction maneuver
Elbow held in hyper flexion. Fore arm held in pronation – if distal fragment
is postero medially displaced,
Fore arm held in supination -- if distal fragment is postero laterally displaced.
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Indications for open reduction
Open reduction is indicated to obtain alignment if closed reduction is unsuccessful as with the following,
Button holing of the proximal fragment through the anterior soft tissues ,
Interposition of the biceps ,
Interposition of the neurovascular structures .
An open reduction is also indicated if there is an open fracture ,that requires irrigation and debridement .
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Complications Immediate : a) neurological b) vascular Early : a) compartment syndrome b) volkmann`s ischemia Late : a) mal union : cubitus varus / cubitus
valgus b) volkmann`s ischemic contracture c) myositis ossificans d) elbow stiffness