Extern conference สารัช 1 ส.ค.61

1. Extern Orthopedic conference
Ext Saraj Choeypunt
PCM

2. Patient profile
• ผู้ป่วยชายไทยคู่ อายุ 64 ปี
• ไม่ได้ประกอบอาชีพ
• ภูมิลาเนาจังหวัด นครราชสีมา

3. Chief complaint
• ปวดแขนซ้าย 2 ชั่วโมง ก่อนมาโรงพยาบาล

4. Present illness
• 2 ชั่วโมงก่อนมาโรงพยาบาล ผู้ป่วยให้ประวัติว่าขณะนั่งมอเตอร์ไซค์ เกิดชน
มอเตอร์ไซค์ล้มเอง เอาแขนซ้ายกระแทกพื้น ไม่มีศีรษะกระแทกพื้น สวมหมวกกัน
น็อก ไม่หมดสติ มีอาการปวดต้นแขนซ้าย แขนซ้ายผิดรูปและบวม ไม่มีแผล ไม่เจ็บ
หน้าอก ไม่ปวดท้อง เดินได้ปกติ

5. Primary survey
• A: airway patent, able to talk, no posterior cervical spine tenderness
• B: Spontaneous breathing, RR 16 bpm, equal chest expansion, trachea
in midline, CCT negative, clear and equal breath sound both lungs
• C: BP 158/97 mmHg, PR 74 bpm, no external bleeding, no pelvic
tenderness or ecchymosis, abdomen soft not tender, PCT negative
• D: E4V5M6, pupil 3mm RTLBE
• E: tender at left forearm , left forearm swelling and deformity ,
neurovascular intact.

6. Secondary survey
• A: No history of drug or food allergy
• M: No current medications
• P:
• No underlying disease, no history of previous surgery
• Last meal: 18.00
• E: as above

7. Physical Examination
• Vital sign: BT 37.0 c PR 74 bpm RR 20/min BP 158/97 mmHg
• GA: Good consciousness, well cooperated, not pale
• HEENT: no pale conjunctivae, anicteric sclerae, no subconjunctival
hemorrhage, no evidence of head trauma, no contusion
• Lungs: Equal chest expansion, equal breath sound, no accessory
muscle used, clear and equal breath sound both lungs
• CVS: JVP not engorged, pulse full and regular all extremities, normal
S1S2, no murmur

8. Physical Examination
• Abdomen: No distention, no contusion, soft, not tender, normoactive
bowel sound, no guarding, no rebound tenderness
• Extremities: left forearm deformity and swelling, no redness, no open
wound, marked tender at left forearm and wrist, no tenderness at knee
or ankle, capillary refill <2sec, radial pulses 2+, limit of ROM of Lt.
arm due to pain, no decrease pinprick sensation.

9. Adjunct to secondary survey
• Film left forearm, wrist AP lateral

13. Management
• Admit
• CBC,BUN,Cr,Electrolyte,anti-HIV
• CXR
• EKG 12 leads
• pain control
• On long arm AP slab in full supination
• Film left forearm, wrist AP lateral after on long arm AP slab

14. Diagnosis
• Fracture of midshaft to1/3 distal radius and distal
radioulnar joint dislocation

15. Galeazzi fracture

17. Etiology
• Most often in males
• About 7% of all forearm fractures in adults

18. Mechanism
• Fall on an outstretched hand with marked pronation of the
forearm.
• Direct trauma to the wrist, typically on the dorsolateral side
of the forearm

19. Associated injury
• Dislocation of the distal radioulna joint is usually dorsal.
• Ligamentous injury
• Fracture of the styloid process of the ulna
• Anterior interosseous nerve palsy
• Triangular fibrocartilage complex injury

21. Sign and symptoms
Symptoms
Pain ,Swelling and deformity of the lower end of the forearm.
Pronation and Supination are severely restricted
Limit range of motion due to pain , Stepping (features of fractures)
Signs
Prominence or tenderness over the lower end of ulna

22. Physical examination
• Evaluate for compartment syndrome , check radial pulses , capillary
refill
• Anterior interosseous nerve exam
• DRUJ instability

25. Plain radiograph
AP view Lateral View
Fracture radius , transverse or short oblique Radius is angulated dorsally
Comminution is less Head of the ulna is prominent dorsally
Distal radioulnar joint dislocation
Radius appears short

27. Treatment
• Reduction for complete restoration of muscle functions, rotation of the
forearm.
• Difficult to achieve perfect reduction by conservative methods in adult
• In adult , open reduction and internal fixation of the radius with a plate
is the preferred method of treatment.
• Long arm splint in full supinate position 6 weeks (for DRUJ stability)
and early motion .

28. Complications
• Nonunion and malunion (displacement of the fragment)
• Deformity and limitation in supination and pronation
• Angulation of the fracture and DRUJ subluxation