conference for medical student

1. Conference
interesting case
Apiwan Prasitchai

2. “Patient profile Thai female, 52 years old
Chief complaint
Pain on left wrist for 3 hours

3. Present illness
3 hours prior to hospital, during the patient
took a back ridding for her grandchildren with
both hands on her back, she slipped with left
hand hit on the floor. Then her left wrist was
pain immediately without open wound.
No other pain on the body.

4. Personal history
no underlying disease
no known drug and food allergy
no current medication
Past illness
none

5. Physical examination
Primary survey – normal
Vital signs – BP 124/76mmHg
PR 82/min RR 18/min T 36.8C
Left wrist – swelling, mild deformity,
no wound, tender at distal radius
and distal ulnar, no piano key sign,
limit ROM, *neurovascular intact
Other extremities – no tenderness

7. Film left wrist

8. Diagnosis?
Close fracture left distal radius and ulnat styloid

9. Initial management
Close reduction under anesthesia
short arm AP slab with three point fixation

10. Film left wrist

11. Distal end radius fracture
Definition - fracture site <,= 1.5 inches from radiocarpal joint
Fernandez classification – base on mechanism of injury

12. Distal end radius fracture
Associated injuries
DRUJ injuries
Radial styloid fracture
Radiocarpal dislocation
Investigations
Film wrist AP and lateral
Treatment
Nonoperative – close reduction with immobilization
Operative

13. Close reduction
• Traction
• (Disimpaction)
• Volar flexion
• Ulnar deviation

14. Indication of surgery
Unstable
Irreducible fracture
Unacceptable alignment
Open fracture
Associated injury

15. unstable
• Fernandez type II, IV, V and some case in I, III
• Lafontaine criteria >=3/5
• Secondary displacement after casting
Lafontaine criteria
1. Dorsal angulation > 20
2. Ulnar Fx
3. Dorsal comminution
4. Intraarticular Fx
5. Age > 60 years

16. Irreducible Fx
• Double die punch
• Articular step off > 2 mm
• Shortening > 5 mm
• Severe comminution
Unacceptable alignment
• Articular step off > 2 mm
• Shortening > 5 mm
• Dorsal tilt > 10
• Volar tilt > 20
• Radial inclination <15

17. Advice
• ใส่ arm sling ให้ข้อมือสูงเหนือหัวใจ และเวลานอนให้วาง
บนหมอนเหนือระดับหัวใจเช่นเดียวกัน เพื่อลดบวม
• ถ้ามีอาการของ compartment syndrome ให้รีบมาพบ
แพทย์ทันที
• six pack exercise of hand
• full ROM of other joint

18. Six pack exercise

19. Follow up
• change cast/slab
• clinical union evaluation
• prevent complication
• X-ray for radiologic union evaluation

20. References
เอกสารประกอบการเรียนเวชปฏิบัติทางออร์โธปิดิกส์
โรงพยาบาลนครราชสีมา
หนังสือ Orthopaedic Trauma คณะแพทยศาสตร์
มหาวิทยาลัยเชียงใหม่
www.orthobullets.com

21. Thanks!
Any questions?