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Extern orthopedic conference
Ext. Prima Boonveerabut23rd Jan, 2017
Patient profile• ผปวยชายไทย อาย 22 ป• สถานภาพ โสด• ภมลำาเนา อำาเภอคง จงหวดนครราชสมา
• มาโรงพยาบาลมหาราชนครราชสมา วนท 21 มกราคม 2560 เวลา 10.00 น
Chief complaint• ปวดไหลซาย 3 ชวโมงกอนมาโรงพยาบาล
Present illness• 3 ชวโมงกอนมาโรงพยาบาล ผปวยลมจากเตยง
แลวเอามอซายยนพนไว จากนนมอาการปวดไหลซาย รสกไหลซายหลด ยกแขนซายไมได ขยบมอได ปวดไหลซายมากจงมาโรงพยาบาล
Primary survey• A : Can speak, c-spine not tender, full
ROM of neck• B : Equal breath sound, CCT negative• C : BP 142/75 mmHg, PR 105 bpm, no
active external bleeding• D : E4V5M6, pupil 3 mm RTLBE• E : No external wound, deformity and
limit ROM at left shoulder
Secondary survey• A : ปฏเสธประวตแพยาหรอแพอาหาร• M : ปฏเสธยาทใชประจำา• P : ปฏเสธประวตโรคประจำาตว• L : NPO 7.00 น. 21 มกราคม 2560• E : ผปวยลมจากเตยงแลวเอามอซายยนพนไว จากนนม
อาการปวดไหลซาย รสกไหลซายหลด ยกแขนซายไมได ขยบมอได เคยไหลซายหลด 2 ครงในชวง 2 เดอนทผานมา
Physical examination• General appearance : A Thai man, alert,
well co-operative• Vital signs: BP 142/75 mmHg, PR 105
bpm, RR 18 bpm, BT 36.5 ำC• HEENT : Not pale conjunctivae,
anicteric sclera• Heart : Normal S1S2, no
murmur• Lung : Clear both lungs• Abdomen : No distension, soft, not
tender• Neurological : Grossly intact
Physical examinationLeft shoulder • Flatten left deltoid,
deformity, mild swelling, tender, limit ROM all direction
• Duga’s test positive, Ruler test positive
• Neurovascular : intact
Investigation• Film left shoulder AP• Film left shoulder transcapular
Film left shoulder AP
Film left shoulder
transcapular
Diagnosis• Anterior left shoulder dislocation
Management• Pain control with MO 5 mg IV stat• Closed reduction : Traction-
countertraction• On interlocking arm sling• Film left shoulder AP, left shoulder
transcapular หลง closed reduction• Home medication : Paracetamol (500) 1
tab oral prn for pain q 4-6 hr• Follow up 2 weeks
Film left shoulder AP
Film left shoulder
transcapular
Shoulder dislocation
Shoulder (Glenohumeral) dislocation• Most commonly dislocated joint in
the body• Can occur anteriorly (95-97%),
posteriorly (2-4%), inferiorly, or anterior-superiorly
• Previous shoulder dislocation are more prone to redislocation
Tissue does not heal properly and/or tissue stretches out and becomes more lax
Shoulder (Glenohumeral) dislocation• Shoulder stability Glenohumeral ligaments : Inferior
glenohumeral ligament Joint capsule Rotator cuff muscles Negative intra-articular pressure : Suction
cuff effect by capsule & labrum Bony/cartilaginous anatomy
Shoulder (Glenohumeral) dislocation• Patients who tear their rotator cuffs or
fracture the glenoid during their shoulder dislocation have a higher incidence of redislocation
Mechanism of injury• Anterior dislocation abducted, externally
rotated, extended arm eg. Blocking a basketball shot, posterior
force, fall on an outstretched arm• Posterior dislocation adducted,
internally rotated arm eg. Seizure
Radiographic
anatomy
Humerus :
(1) Scapula (Y) : (2) Glenoid
fossa : (3)
Anterior shoulder dislocation : Subtype• Subcoracoid
(90%)• Subglenoid• Subclavicle• Intrathoracic
Clinical presentation & Physical examination Clinical presentation• Pain on affected side• Arm is in slight abduction and external
rotation• Loss of normal of the shoulderPhysical examination• Anterior bulge of head of humerus may
be visible/palpable• Limited ROM• Special test : Dugar’s sign, Ruler’s sign
Associated injury of shoulder dislocation• Stretching/tear of
capsule• Avulsion of
glenohumeral ligament• Labral injury : Bankart
lesion• Impression fracture :
Hill-Sachs lesion• Rotator cuff tear• Injury to axillary nerve
Complication** : Recurrent dislocation
Hill-Sachs lesion
Bankart lesion
ManagementNon-operative• Closed reduction• Film X-ray confirmed after reduction• Immobilization : Interlocking sling• Pain control• Rehabilitation Operative
Closed reduction1. Hippocretes
method2. Traction-
countertraction3. Stimson’s
method4. Milch’s
technique5. Kocher’s
technique
Follow up care• Immobilized in adduction
and internal rotation for 3 week in patient under
30 years old : Risk of redislocation
For 1 week in patient over 30 years old and early mobilization
• Rehabilitation
Operative treatmentIndication• Failed non-operative treatment• Irreducible dislocation• Open dislocation• Recurrent dislocation in young age
THANK YOU