General Data: Chief Complaint: History of the Present Illness: Case Presentation and Discussion on Extremity Trauma

Transcription

1 Case Presentation and Discussion on Extremity Trauma General Data: By: Roderick S. Mujer MD. 3 rd year Resident Department of Surgery Ospital ng Maynila Medical Center P.N., 48-year- old, male from Malacanang Park Manila. Chief Complaint: History of the Present Illness: Swelling of right hand Few minutes PTA Patient fell on the ground on his outstretched hand after he was allegedly hit by a fast moving vehicle CONSULT

2 Past Medical History: No known history of Allergy No previous operation Physical Examination: Conscious, coherent, NICRD BP 100/70mmHg CR: 90bpm RR: 22cpm Temp: 37.1 Pink palpebral conjunctivae, anicteric sclerae Supple neck, no cervical lymphadenopathy Physical Examination: Symmetrical chest expansion, no retractions, clear breath sounds Adynamic precordium, no murmur Flat abdomen, normoactive bowel sounds, soft, non-tender Physical Examination: (+) structural deformity (+) limitation of movement (+) Pain and tenderness (+) swelling right hand (-) pallor Good capillary refill Intact neurologic exam

3 Salient Features Algorithm 48-year-old, male Swollen right hand (+) structural deformity (+) limitation of movement (+) Pain and tenderness (+) swelling right hand (-) pallor Good capillary refill Intact neurologic exam Injured Extremity PE Extent of Injury Superficial Skin Subcutaneous Muscle Neurovascular Deep Tendon Bone Clinical Diagnosis Paraclinical Diagnostic Procedure Primary Secondary Diagnosis Soft tissue swelling with bone fracture Soft tissue swelling without bone fracture Certainty 80% 20% Treatment Surgical Medical Medical Do I need a paraclinical diagnostic procedure? Yes

4 PARACLINICAL OPTIONS X- Ray BENEFIT RISK COST AVAILABILITY X-RAY SR= 90% Radiation 100 Available CT SCAN SR= 90-97% Radiation 3500 Available nearby MRI SR= 95% Radiation 7000 Available nearby Dorsal displacement and angulation of distal radius Pre-Treatment Diagnosis Goals of Treatment Primary Secondary Diagnosis Complete angulated fracture of distal radius right without nerve injury Complete angulated fracture of distal radius with nerve injury Certainty 95% 5% Treatment Surgical Surgical Improve cosmetic deformity Restoration of good wrist and hand function Function

5 Treatment Options BENEFIT RISK COST AVAILABILITY Plan of Operation Closed reduction with Plaster immobilization Closed reduction with External fixation Closed Reduction with External Fixation Open reduction with Internal fixation Pre-operative Preparation Informed consent -Plan Carefully explained to relatives Psychosocial support Optimize patient s health Screen for any condition that will interfere with treatment Prepare materials for OR Intra- Operative Patient placed supine under GETA Longitudinal traction applied using chinese finger traps Counter weight to the humerus and the elbow at 90% flexion Reduction performed Asepsis/Antisepsis

6 Intra- Operative Intra- Operative Sterile drapes placed Metacarpal pin insertion done Radial pin insertion Intra- Operative Intra- Operative Side Frame applied

7 Intra- Operative Operation Done Correct instruments and sponge count Patient tolerated the procedure well Closed Reduction External Fixation Final Diagnosis Complete angulated Fracture of distal Radius, right S/P Closed Reduction; External Fixation Post-operative Management Basic needs supplied - Antibiotics - Analgesia -Comfort Elevate affected extremity Wound checked

8 Follow Up care 6 weeks post Op - repeat X-ray 8 weeks post op - refer to rehabilitation medicine for active range of motion exercise Discussion Colles Fracture fracture of the distal radius with dorsal angulation dinner fork deformity of the wrist Result of a fall on the outstretched hand Stages of Fracture Healing Stage of Impact -Periosteal stripping, soft tissue injury Stage of inflammation -1-2weeks -hematoma attracts inflammatory cells Discussion Early reparative stage - stage of soft callus - weeks to months - granulation tissue forms in fracture gap - osteoblastic proliferation - cartilage form centrally

9 Discussion Late reparative stage - stage of hard callus - weeks to months - calcification of cartilage Remodelling stage - months to years - bone tends toward original shape - medullary cavity reconstituted - woven to lamellar bone Discussion Bone can heal either by: Membranous ossification -direct bone formation Endochondral ossification -indirect bone formation -cartilage followed by bone Factors Influencing Fracture Healing Systemic Factors Age Nutritional status Hormonal factors Diseases Vitamin defficiency Drugs Discussion Local Factors Abnormal bone Dervation Degree of local damage Type of fracture Extent of contact between fragments

10 Immobilization Mechanical factors are of utmost important in maintaining the equilibrium between resorption and formation. If resorption exceeds formation, osteopenia will result Complications Extensor Pollicis longus rupture Median nerve compression Malunion RSD Distal radio-ulnar joint injury If formation exceeds resorption, an absolute increase in bone mass will follow. REFERENCES 1. Seitz-WH Jr; Froimson-AI; Brooks-DB; Postak-PD; Parker-RD; LaPorte-JM; Greenwald-AS, Biomechanical analysis of pin placement and pin size for external Clin-Orthop Feb(251): Trumble TE, Wagner W, Hanel DP, Vedder NB, Gilbert M. Intrafocal (Kapandji) pinning of distal radius fractures with and without external fixation. Department of Orthopaedics, University of Washington Medical Center, Seattle , USA. 3. Carrozzella m-j., Stern-P-J. Treatment of comminuted distal radius fractures with pins and plaster. Hand-Clin Aug. 4(3). P REFERENCES 4. Altissimi [m-m. Antenucci [m-r. Fiacca-C. Mancini-G-B. Long-term results of conservative treatment of fractures of the distal Clin-Orthop May. (206). P Grewal R, Perey B, Wilmink M, Stothers K, A Randomized Prospective Study on the Treatment of Intra-Articular Distal Radius Fractures: Open Reduction and Internal Fixation With Dorsal Plating Versus Mini Open Reduction, Percutaneous Fixation, and External Fixation; Department of Orthopedics, University of British Columbia, Vancouver, British Columbia, Canada. December 2003; accepted 26 April 2005

11 MCQ 1. What is the process of healing wherein bone forms after cartilage formation? a. Membranous ossification b. Hematoma formation c. Endochondral ossification d. Direct healing MCQ 2. Which among the following histologically visible responses to a fracture segment occurs first? a. Cellular Proliferation b. Cellular Differentiation c. Collagen Formation d. Calcification MCR 3.The following are systemic factors that influence fracture healing except? 1. Diabetes 2. Corticosteroid use 3. Nutrition 4. Comminution of Fracture MCR 4. The following cytospecific differentiation, involves in the process of fracture repair : 1. Mesenchymal cell proliferation 2. Cartilage formation 3. Formation of lamellar bone 4. Interfragmentary gap

12 MCR 5. The following are known complications of Colle s fracture: 1. Median nerve compression 2. Malunion 3. Distal radio-ulnar joint injury 4. RSD Thank You!