Extern conference
BY NITHIT SEMSAWAT
PI 5422054
ผปวยหญงไทยคอาย 58 ป ภมล าเนา อ าเภอเมอง จงหวด นครราชสมา
สทธประกนสขภาพถวนหนา
Chief complaint
ลมไหลซายกระแทกพน 3 วน PTA
Primary survey
• A : can talk , no cervical spine tenderness , full ROM of neck
• B : equal breath sound , no adventitious sound, CCT neg
• C : BP 119 / 76 mmhg , PR 98/min , RR 20 / min
, T 36 C , no visible site of active bleeding.
• D : E4V5M6, pupil 3 mm RTLBE
• E : No External wound
Secondary survey
• A : no drug allergy
• M : no current medication
• P : no underlying disease
• L : last meal 4 hr PTA
• E : 3 day PTA ลนหกลมไหลซายกระแทกพน เจบแขนซาย ยกแขนไดเลกนอยเนองจากปวด บวมเลกนอย ไมมแผลดานนอก ไมมอาการชาทไหล ไมมเลอดออก ไมมอาการเจบบรเวณอน ไมสลบ ขยบขอมอไดปกต
Physical examination
• Vital signs : BP 119 / 76 mmHg , PR 98/min , RR 20 / min , T 36 C
• General appearance : A Thai women good consciousness, well co operative
• HEENT : not pale, no jaundice
• Lung : clear , equal breath sound both
• CVS : normal s1s2, no murmur
• Abdomen : soft not tender
• Neuro : E4V5M6 , orientated to time place person
Extremieties : Left shoulder
• Tenderness, mild swelling, limited ROM due to pain, no deformity, no ecchymosis at left shoulder , no numbness at deltoid area
• Brachial pulses 2+
• Radial pulse 2+ • No wrist drop
Investigation : Film left shoulder AP, Transcapular
Diagnosis
CFX left humeral neck
Management
• On Arm sling
• F/U 2 wk + Film left shoulder AP, Transcapular
• Home medication
– Paracetamol [500] 1 tab oral prn for pain q 6 hr
– Tramol [50] 1*3 oral prn for pain
Fracture Proximal
Humerus
Outlines
• Epidemiology and risk factors
• Signs and symptoms
• Physical Examination
• Radiographic findings
• Neer classification
• Indication for referral
• Follow-up care
• Return to sport or work
Epidemiology and risk factors
• Incidence 4-5 % of all fractures
• Incidence increases with age
– > 70 % occurring in Pt. > 60 yr.
• 3-4 times more common in females
• Risk factors
– Frequent falls
– Low bone density
Signs and symptoms
• Shoulder pain that increases with shoulder movement
• Swelling and ecchymosis
• Shoulder deformities
Physical Examination
• No specific examination tests for diagnosis • Typically have focal tenderness at proximal
humerus • Neurovasucular injury
– Axillary nerve • Deltoid m. weakness • Decrease sensation of mid-deltoid region
– Suprascapular nerve • Supraspinatous and infraspinatous m. weakness
• Vasucular injury – Circumflex artery
Radiographic findings
• Film shoulder AP , transcapular
• CT with three dimensional reconstructions [if Plain film can’t diagnostic]
Film shoulder AP
Film Transcapular view
Fracture patterns : Neer classification
• Non – displace VS Displaced
1. Displaced > 1 cm
2. Angulation > 45 degrees
• Fracture classified
– One-part Fracture
– Two-part Fracture
– Three-part Fracture
– Four-part Fracture
Displaced
Non-Displaced
Displaced
Indication for referral
• 80 % are non-displace or minimally displace – Can conservative at primary care clinicians
• Displaced [2-4 part fractures]: need surgery – Refer to orthopedic surgeon for evaluation
- Osteosynthesis - Percutaneous pinning
- ORIF - Hemiarthroplasty
• Emergency referral – all nerve and vascular injuries – Fracture dislocation
Initial treatment
• Immobilization – Standard sling : impact fracture – Collar and cuff sling
• Reduction of minimally displaced fragments
– Swathes : use in shoulder unstable • Pain control
• Ice : reduce pain and swelling • Pain control medication • Close reduction of fracture fragments is not
recommended – Because several muscles have insertions on the proximal
humerus
Follow-up care
• Total healing is typically 6-12 wks
• Early callus formation usually occurs a 4-6 wks
• Duration of immobilization – 1-2 wks initiated ROM exercises
Follow-up care: Reevaluation
• 7-14 days Reevaluation for significant displacement
• If pain is well controlled and no displacement fragments
– Pendulum exercises : decrease loss of shoulder motion
– Isometric strengthening exercises for the biceps and triceps
Pendulum exercises Isometric strengthening exercises
Follow-up care : Subsequent visits
• 2 - 4 wks after surgery
– Encourage to discontinue their sling
– Passive range of motion exercise of the elbow and shoulder : Twice daily
• Pendulum exercise
• Wall climbing exercise
• Consult PT for passive ROM if necessary
• Serial follow up q 2-4 wks for evaluation and improve range of motion
Wall climbing exercise
Follow-up care : Complications
• Loss of shoulder mobility : most common
• Neurovascular injury
– Circumflex artery
– Axillary or suprascapular nerve
– Rotator cuff tear [if dislocation of humeral head ]
• Osteonecrosis of Humeral head [uncommon]
Return to sport or work
• Work : 3 wks after proximal humerus fracture
– Not full use of the affected arm
– 8-12 wks if jobs includes two-handed labor
• Sports
– Adequate range of motion
– Strength as well as stable callus formation on radiographs
Take home message
• Non displace fracture
– Conservative
– Early ROM exercise
• Displace fracture
– Refer to orthopedic surgeon for evaluation