EXTERNCONFERENCE

EXT. ANYAMANEE

PATIENT PROFILEผปวยเดกหญงไทย อาย 4 ป 6 เดอน ภมลำาเนาอำาเภอดานขนทด จงหวดนครราชสมาcc: ลมกระแทกพน 5 ชวโมงกอนมา รพ.PI: 5 ชวโมงกอนมารพ. ขณะวงเลนกบเพอนทโรงเรยน มการกระแทกกน แลวลม แขนขางซายกระแทกพน มอาการปวดบรเวณขอพบแขนซายมาก ขยบงอแขนไมได ขอศอกผดรปมบาดแผลถลอกเลกนอยบรเวณขอพบ คณครจงนำาสงทรพ.ดานขนทด แลวสงตวมารกษาตอทรพ.มหาราชนครราชสมา

PHYSICAL EXAMINATION• A : PATENT AIRWAY, CAN FLEX NECK, • B : RR 22/MIN, EQUAL CHEST MOVEMENT, LUNG CLEAR, CCT –

NEG• C : BP 100/60 MMHG, HR 109/MIN• D : E4V5M6, PUPILS 3 MM IN DIAMETER REACT TO LIGHT

BOTH EYES• E : DEFORMITY LEFT ELBOW, ABRASION WOUND SIZE 1*3 CM

AT LEFT ARM WITH ECCHYMOSIS SIZE 3*3 CM

PAST HISTORY NO UNDERLYING NO HISTORY OF BONE FRACTURE NO HISTORY OF OPERATION NO HISTORY OF DRUG ALLERGY NO PREMEDICATION LAST MEAL 15.30 PM

PHYSICAL EXAMINATION• HEAD: NO EXTERNAL WOUND• MAXILLOFACIAL&OROFACIAL: CAN OPEN MOUTH, NO EXTERNAL

WOUND OR CONTUSION AT FACE, NO THEETH LOSS• CERVICAL SPINE & NECK : NOT TENDER ALONG C-SPINE, CAN

FLEX NECK• CHEST : LUNGS CLEAR AND EQUAL BREATH SOUND, NO

ADVENTITIOUS SOUND, NO STEPPING AT CHEST WALL AND NOT TENDER, NO EXTERNAL WOUND AND CONTUSION AT CHEST

• ABDOMEN : SOFT, NOT DISTEND, NOT TENDER, NO EXTERNAL WOUND OR CONTUSION

• NEUROLOGICAL : ALERT, MOTOR POWER GRADE V AT RT UPPER LIMB, BOTH LOWER LIMB

PHYSICAL EXAMINATIONExtremities : left arm Deformity Ecchymosis & Abrasion

wound Swelling Tenderness & Pain on

motion Limit ROM of elbowExtremities : left hand Radial & ulnar pulse can

palpableThumb extensionThumb palmar abductionThumb adductionFinger adductionNormal sensation

DIAGNOSIS

SUPRACONDYLAR FRACTURE OF LEFT HUMERUS

EARLY TREATMENT AT ER

LONG ARM A-P SLAB PETHIDINE 19 MG IV FOR PAIN CONTROL

DEFINITIVE TREATMENTSURGERY : CLOSE PINNINGON POSTERIOR SLAB 4 WKOBSERVE COMPARTMENT SYNDROME AND NEUROVASCULAR INJURY

SUPRACODYLAR FRACTURE

DISTAL HUMERUS ANATOMY

DEFINITION FRACTURE THAT INVOLVE LOWER END OF HUMERUS USALLY INVOLVING THE THIN PORTION OF THE HUMERUS THROUGH OLECRANON FOSSA OR JUST ABOVE THE FOSSA OR METAPHYSIS

MECHANISM OF INJURY

fall on outstretched hand(Extension type)

MECHANISM OF INJURY

Fall Directly on the elbow(Flexion type)

CLASSIFICATIONGARTLAND CLASSIFICAITON

ASSOCIATED INJURIES

1.Neuraplexia•anterior interosseous nerve neurapraxia (branch of median n.)

the most common nerve palsy seen with supracondylar humerus fractures

•radial nerve palsysecond most common neurapraxia (close second)

•ulnar nerve palsyseen with flexion-type injury patterns

ASSOCIATED INJURIES2.VASCULAR INJURY 3.COMPARTMENT SYNDROME

PRESENTATION• SYMPTOMS

• PAIN• REFUSAL TO MOVE THE ELBOW

• PHYSICAL EXAM• INSPECTION

• GROSS DEFORMITY• SWELLING• BRUISING

• MOTION• LIMITED ACTIVE ELBOW MOTION

PRESENTATION: NERVE EXAM

•AIN neurapraxia  •unable to flex the interphalangeal joint of his thumb and the distal interphalangeal joint of his index finger (can't make A-OK sign)

•radial nerve neurapraxia•inability to extend wrist or digits may be •present due to radial nerve injury neurapraxia

PRESENTATION VASCULAR EXAM

VASCULAR INSUFFICIENCY AT PRESENTATION IS PRESENT IN 5 -17%

DEFINED AS COLD, PALE, AND PULSELESS HAND

COMPARTMENT SYNDROME EXTEND FINGER

IMAGINGAP AND LATERAL X-RAY OF THE ELBOW

MEASUREMENT IMAGING•displacement of the anterior humeral line

•anterior humeral line should intersect the middle third of the capitellum  •capitellum moves posteriorly to this reference line in extension type fracture 

MEASUREMENT IMAGINGAlteration of Baumann angle  

Baumann's angle is created by drawing a line parallel to the longitudinal axis of the humeral shaft and a line along the lateral condylar physis as viewed on the AP image  normal is 70-75 degrees, but best judge is a comparison of the contralateral sidedeviation of more than 5 degrees indicates coronal plane deformity and should not be accepted

TREATMENTTYPE 1

LONG ARM SLAB 3 WEEKS TYPE 2

CLOSE REDUCTION THEN ON LONG ARM SLAB3-4 WEEKS (ELBOW FLEXION 60-90 DEGREE)

TYPE 3SURGERY PERCUTANEOUS PINNING ORIF WITH K-WIRE

COMPLICATIONPin migration

most common complication (~2%)Infection

occurs in 1-2.4%typically superficial and treated with oral antibiotics

Cubitus valguscaused by fracture malunioncan lead to tardy ulnar nerve palsy

Cubitus varus (gunstock deformity) caused by fracture malunion  usually a cosmetic issue with little functional limitations

COMPLICATIONVASCULAR INJURY

PULSELESS HAND AFTER CLOSED REDUCTION AND PINNING (3-4%) VOLKMANN ISCHEMIC CONTRACTURE

INCREASE IN FOREARM COMPARTMENT PRESSURES AND LOSS OF RADIAL PULSE WITH ELBOW FLEXED GREATER THAN 90°POSTOPERATIVE STIFFNESS