case presentations trauma c.janelle sporc2012

7/30/2019 Case Presentations Trauma C.janelle SPORC2012

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Case Presentations

TRAUMA

S.P.O.R.C. 2012

Dr. Chantal Janelle


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Case 1- S.C.

7 Y.O. healthy boy, C/O L elbow pain.

Fell skiing on outstretched L hand earlieron today.

Patient transferred from a peripheralhospital where he had a manipulation of Lelbow under sedation.


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Case 1- S.C.

Current assessement:

C/O L elbow pain

Exam out of slab: Diffuse moderate swelling L

elbowPain ++ lateral aspect

Neurovasc. Intact distally

Discussion

X-rays (next slide)


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Case 1- S.C.


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Case 1- S.C

X-Rays L forearm

Management?


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Case 1- S.C.

Ct- Scan L Elbow

Management?


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Case 1- S.C

Under G.A. : Attempt at closed reductionis unsuccessful

Retrograde elastic nailing L radius up tofracture

Open reduction of fracture (Kocherapproach)

Elastic nail advancement into proximalfragment


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Case 1- S.C

Intra op X-Rays


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Case 1- S.C

Post-op regimen?

Potential complications?


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Case 2 N.V.

15 Y.O. healthy boy

Soccer injury: Patient was about to kick the ballwhen an opponent facing him kicked his leg.

P/E: Swelling +++ and pain L kneeUnable to contract quad. or to lift leg from thebed

N neuro-vascular exam distally

Discussion?

X-Rays(next slide)


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Case 2 N.V.

X-Rays L knee

Management?


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Case 2 N.V.

Patient taken to O.R.O.R.I.F.

Post-op regimen?


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Case 2 N.V.

Post-op: Cylinder cast x 6 weeks,toe touchAROM / strenghtening / WBAT at 6weeks


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Case 3 B.L.

14 y.o. fell off a snow skate x 24hTransferred from a regional hospital .C/O pain L ankle, immobilized in a post. slab .

P/E:Swelling ++++ L ankleN sensation, moves toes in FL/EXTN cap.refill

Compartments are soft

Discussion?


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Case 3 M.L.-P.

X-Rays L ankle:

Discussion?


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Case 3 M.L.-P.

Attempt at closed reduction underketamine sedation: unsuccessful

Management?Above knee posterior slab

R.I.C.E.

AdmissionCT-SCAN


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Case 3 M.L.-P.CT-SCAN ( transverse) :


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Case 3 M.L.-P.

CT-SCAN (sagittal) :


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Case 3 M.L.-P.CT-SCAN (coronal) :


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Case 3 M.L.-P.

Management?

Patient D/C homePt return in clinic 10 days later

P/E: Swelling improved, skin wrinkles +

NV intactFinal Treatment?


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Case 3 M.L.-P.

ORIF L ankle:

1- Ant. approach for O.R. of Tillaux andmed. mall. fx

2-ORIF of post. fx with use of a pelvicclamp,(post.-lat. approach)

3-internal fixation Tillaux and med.mall.

4- Fibular fx stable ,therefore not fixed


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Case 3 M.L.-P.


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Case 3 M.L.-P.

10 days post-op:Wounds are clean, staples removed

Full below knee cast,NWB with crutches


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Case 3 M.L.-P.

6 weeks post-op:

Start ROM and PWB


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Case 4 - C.S.

9 y.o. female RHD

Fell off a trampoline, landed on R elbowC/O pain R elbow

P/E: Deformity R elbow

1 cm wound and bruising ant.-med. aspect R elbowDecreased sensation over volar aspect of TF,IF,MF.

Weakness of FPL and FDP IF and TF opposition.

Weak, intermittent radial pulse.

Cap. Refill : 2-3 sec.

Diagnosis?

Discussion?

C 4 C S


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Case 4 - C.S.X-Rays R elbow :

Management?


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Case 4 - C.S.

I.V. antibiotics, ( tetanus vacc. up to date)Wound debridement

O.R.I.F. with K-Wires, post. slab

Vascular exploration :( - )


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Case 4 - C.S.

At 4 weeks : Cast and K-W removed

start ROM / strengthening

At 12 weeks:

P/E: thenar atrophy, decreased sensationTF,IF,MF(improved from before)

FPL and FDP IF : 3+/ 5

Finger ABD and EXT: 5 / 5

ROM elbow : 30-110 P/S: 80/90 Wrist : N

X-Rays: Fx healed


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Case 4 - C.S.At 6 months:

Sensation assessed by monofilaments (O.T.):Protective sensation over TF,IF,MF

FPL and FDP IF: 4+/5

Thumb abduction: 4/5ROM elbow: 15 FL -130 FL (vs 10 hyperext.-150 FL)


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Case 5 - P.-S.M.

5 y.o. boy

HX :

MVA, low velocity impact No loss of consciousness Pain bilateral lower extremities

Diffuse abdominal pain

P/E : Stable V.S. Normal level of consciousness

Abdomen: Tenderness (L) lower quadrant Swelling / deformity bil. thighs, no wound (N) NV exam bilaterally

Discussion


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Case 5 - P.-S.M.

Labs:

Normal

X-Rays:

Bil. femurs (ref.: next slide) Chest: (-)

CT Scan abdomen/pelvis: (-)


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Case 5 - P.-S.M.

X-Rays: AP Pelvis, (R) Femur

C 5 P S M


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Case 5 - P.-S.M.

X-Rays: (L) Femur


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Case 5 - P.-S.M.

Discussion:

Initial management?

Treatment options? Final Treatment?

P.-S. M. (2001-01-12)


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Initial Treatment:

Bilateral skin traction

X-Rays: (R) Femur X-Rays: (L) Femur

Discussion: Final treatment?

P.-S. M. (2001-01-12)


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Case 5 - P.-S.M.

Treatment:

Patient taken to O.R.

closed reduction Elastic nailing

Bilateral femurs

P.-S. M. (2001-01-12)


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Post-Op X-Rays:

X-Rays: (L) FemurX-Rays: (R) Femur

P.-S. M. (2001-01-12)


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Case 6 P.T.

7 weeks old boy, healthy

Brought to E.R. by parents for ROM (L) L.E.

Discussion

Case 6 P T


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Case 6 P.T.

PMH:

N (full-term) pregnancy Born/vaginal delivery Vertex presentation B.W.: 2800g APGAR: 9-9-10

Family History: - Negative

Meds: none

Allergies: none

Discussion


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Case 6 P.T.

HX :

Parents have noticed ROM (L) L.E. x 5 days No fever

No Hx of trauma N Milk intake System review: (-)

Discussion


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Case 6 P.T.

P/E :

N V.S.T : 37.4 C (L) L.E.: ? mild swelling (L) leg, no redness

AROM, N PROM

Otherwise normal MSK exam

Investigation?

Plan?

Case 6 P T


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Case 6 P.T.Patient Admitted under Ortho. Service

Labs: CBC

Hb: 104 (95 135)PLT: 552 000 ()WBC: 12,1 (6,0 - 17,5)

Neutro: 0,17

Lympho: 0,74

Calcium: 2,55 (2,25 2,75)

Phosphorus: 1,90 (1,40 2,90) Sedimentation: 5 CRP: Negative Coagulation workup: Normal


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X-Rays: (L) Lower Extremity

P.T. (2005-12-03)


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X-Rays: (L) Tibia

P.T. (2005-12-03)

X Rays: (L) ankle


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X-Rays: (L) ankle

P.T. (2005-12-03)


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Case 6 P.T.

Differential diagnosis?

Further investigation?

P.T. (2005-12-03)

I ti ti 1


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Gallium ScanBone Scan

Bone Scan & Gall ium Scan : Mild uptake (L) Distal Tibial Physis

Investigation - 1

P.T. (2005-12-03)


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Investigation - 2

Skeletal Survey: Negative

Head CT Scan: Negative

Ophtalmologic consultation: Normalfindings

Pediatric consultation

Social services consultation

P.T. (2005-12-03)


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Case 6 P.T.

Final Diagnosis:- Physeal fracture (L) distal tibia

Final plan:- D.Y.P. involved

Child discharged home

Presence of a family member (grand-father) required at all times with one orboth parents

P.T. (2005-12-03)


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THANK YOU !

case presentations trauma c.janelle sporc2012

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