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EXTERN CASE CONFERENCE
25 Jan 2017By Siravich Thamthitiwat
History Taking เดกชาย อาย 13 ป
เหตเกด 21/1/2017 เวลา 16.30 น. ถง ER เมอ 21.40 น.
Chief Complaint: 5 เจบขอมอซาย ชวโมงกอนมาโรงพยาบาล
History TakingPresent Illness
: 5 ชวโมง กอนมาโรงพยาบาล ผปวยใหประวตวาขณะกำาลงเกดขนบนไดสามเหลยม สงประมาณ 50 ซม. ผปวยเสยหลกลม ใชแขนและขอมอซายกระแทกลงกบพน มอาการปวดบรเวณทขอมอซาย ไมสามารถกระดกขอมอได ปฏเสธประวตศรษะกระแทกพน ไมมอาการหมดสต ไปทโรงพยาบาลชมชน จากนนจงสงตวมาเพอรกษาตอทโรงพยาบาล
PE : Primary Survey A : Able to tell name and event,
spontaneous neck movement B : Equal breath sound, CCT –ve, RR :
16/min C : No bleeding at long bone, pelvis,
abdomen, external, Vital sign; BP: 148/78 mmHg, P77 bpm
D : E4V5M6, pupil 3 mm RTLBE E : No tenderness along spine, able to stand
Secondary Survey S : Tenderness at Lt. wrist, no
ecchymosis A : Denied drug or food allergy M : Denied any current medication P : No known underlying disease L : Last per oral 12.00 E : Fall from small ladder (0.5
meter)
Secondary Survey Head and face : no wound at
scalp and face CVS : normal S1 S2, no murmur Lung : normal breath sound, no
adventitious sound Abdomen : soft, not tender CNS : grossly intact
Secondary Survey Ext. (Lt forearm) : no deformities,
marked swelling, marked tenderness at both medial and lateral aspect of wrist, limit ROM due to pain, able to flex and extend all digits and unable supinate pronation.No external woundNeurovascular : Radial and ulnar pulse 2+Motor : Can’t flexed wrist, able to flexed all phalanges Sensory : Intact
Investigation Lt. wrist AP, lateral
Plain film Lt. wrist AP View
Thurston-Holland’s sign
Plain film Lt. wrist lateral view
Diagnosis Closed fracture of distal radius and
distal ulnar with growth plate injury
Management Pain Control
Pethidine 25 mg IV Closed reduction with long arm AP slabAdvice about slab care, complicationFollow-up on 1/2/2560 with filming HM
○ Paracetamol (500) 1 tab oral prn for pain q 4-6
Plain film Lt. wrist AP after reduction and slab insertion
Plain film Lt. wrist lateral after reduction and slab insertion
Growth plate injury
What is growth plate? Growth plates are found in the
long bones of the body Located one at each end
between the metaphysis and the epiphysis.
When a child is fully grown, the growth plates harden into solid bone.
If left untreated, may lead to unequal or crooked limb.
Growth plate fracture; cause Usually happen with sport
training/activity or fall from height
Twice as often in boys as in girls.
The incidence of growth plate fractures peaks in adolescence.
Clinical Manifestation Visible deformity of the limb An inability to move or put
pressure on the limb Swelling, warmth, and
tenderness
Classification Salter-Harris classification
ClassificationType I Fractures Separating of bone end from the
bone shaft and completely disrupting the growth plate.
Type II Fractures Break through part of the bone at
the growth plate and crack through the bone shaft.
Most common type.
ClassificationType III Fractures Cross through a portion of the growth plate
and through a piece of the bone end. Type IV Fractures These fractures break through the bone
shaft, the growth plate, and the end of the bone.
Type V Fractures Occur due to a crushing injury to the
growth plate from a compression force.
Mnemonic
Other classification
Management Classification determine
managementNon-operativeOperative
Non-operative Salter-Harris type I and II can be treat
with conservative treatmentReduction and immobilization with
splint/slab Children Follow-up every week and splint up to
3-4 weeks
Short arm slab Consider if no distal ulnar fracture seen
Long arm slab
Operative Displacement of more than 2 mm from
distal end to proximal end Salter Harris type III, IV with more than 1
mm displacement Acute carpal tunnel syndrome Associated with ipsilateral elbow fracture
Complication Growth arrest
Complete arrest leads to length discrepancy Partial arrest leads to angulation
Partial arrest of growth plate
Angulation
Complication: treatmentBar resection with interposition indications
< 50% physeal involvement
> 2 years or 2cm growth remaining
Bar resection with interposition
Complication: treatmentIpsilateral completion of arrest indications
> 50% physeal involvementcan combine with contralateral epiphysiodesis and/or ipsilateral lengthening
35
Thank you for your attention