Extern conference extจรรพฤม วพม

1. EXTERN CONFERENCE
Extern Chanprim Ratanasaenghirun
Phramongkutklao College of Medicine

2. Clinical presentation
 Case ผู้ป่วยหญิงไทยโสด อายุ 36 ปี ล้ม 5 hr PTA

3. Primary Survey
 A : Can speak, not tender along c-spine
 B : Equal & normal breath sound, CCT –
ve
 C : BP 154/94 mmHg, PR 88 bpm, no
active bleeding, Abdomen : soft, not
tender
 D : E4V5M6, pupil 3 mm RTLBE
 E : Marked swelling and tender at
anatomical snuff-box, no external
wound

4. Adjunct to Primary Survey
 A : No need
 B : No need
 C : No need
 D : No need
 E : Film right wrist AP, lateral

5. Secondary Survey : History
 Allergy : No known allergy
 Medication : No current medication
 Past illness : No underlying disease
 Last meal : 12.00 04/10/60
 Event : 5 hr PTA รถจักรยานยนต์ที่จอดไว้ล้มลง
ผู้ป่วยจะวิ่งไปจับรถ แต่ลื่นล้ม มือข้างขวา
กระแทกพื้น มีอาการปวดบวมที่มือข้างขวา
มาก ขยับนิ้วโป้งไม่ได้ นิ้วที่เหลือยังขยับได้

6. Physical Examination
 V/S : BP 154/ 94 PR 88 bpm RR 20 bpm
BT 37.1 oc
 GA : A middle age Thai women good
conciousness well cooperate
 HEENT : Not pale conjunctivae, anicteric
sclerae, no eye hematoma, no neck
pain
 Heart : Normal s1 s2, no murmur, pulse full &
regular
 Lungs : Equal chest movement, trachea in
midline, equal tympanic on
percussion, equal breath sound, clear
both lungs

7. Physical Examination
 Abdomen : Soft, not tender, no guarding,
no rebound tenderness.
 Neurological : E4V5M6, pupil 3 mm RTLBE,
motor grade 5 all (except
effected part can’t be
evaluated due to pain),
sensory grossly intact , DTR
2+ all
 Extremities : Tender at right anatomical
snuff-box with mark
swelling ,neurovascular of
distal forearm intact,
capillary refill < 2 sec no
wound, limit ROM due to pain.

8. Film right wrist AP, lateral

11. Radiographic Finding
 comminuted intra-articular fracture-
dislocation of the base of proximal first
metacarpal bone

12. Impression
 Closed fracture base of proximal first
metacarpal bone

13. Base of the thumb metacarpal fractures
 intra-articular fractures
 Bennett fracture
 Rolando fracture
 extra-articular fractures

14.  Epidemiology
 80% of thumb fractures involve the metacarpal
base
 most common variant is the Bennett fracture
Base of the thumb metacarpal fractures

15.  Mechanism of injury
 most fractures caused by axial force applied to the
thumb
 Pathoanatomy
 three muscles provide deforming forces at base of
thumb
 abductor pollicis longus (PIN)
 extensor pollicis longus (PIN)
 adductor pollicis (Ulnar n.)
 the thumb has extensive CMC motion in sagittal
plane
 allows for angulation up to 30 degrees in this plane
Base of the thumb metacarpal fractures

17. Bennett Fracture
 Intra-articular
fracture/dislocation of
base of 1st
metacarpal
characterized by volar
lip of metacarpal
based attached to
volar oblique ligament
 ligament holds this
fragment in place
 small fragment of 1st
metacarpal continues
to articulate with

18.  Pathoanatomy
 lateral retraction of distal 1st metacarpal shaft
by Abductor Pollicis Longus and adductor
pollicis
 shaft pulled into adduction
 metacarpal base supinated
 Prognosis
 better than Rolando fx
Bennett Fracture

19.  Imaging
 recommended views
 fracture best seen with hyper-pronated thumb
view
 findings
 minimal joint step-off considered
Bennett Fracture

20.  Treatment
 Non-operative
 closed reduction & cast immobilization
 Indications : non-displaced fractures
 technique
 reduction maneuver with traction, extension,
pronation, and abduction
Bennett Fracture

21.  Operative
 closed reduction and percutaneous pinning
 indications
 volar fragment is too small to hold a screw
 anatomic reduction unstable
 technique
 can attempt reduction of shaft to trapezium to hold
reduction
 ORIF
 indications
 large fragment
 2mm+ joint displacement
Bennett Fracture

22.  Complications
 post-traumatic arthritis
 there is no agreement regarding the
relationship of post-fixation joint
incongruity and post-traumatic arthritis
Bennett Fracture

23. Rolando Fracture
 Intra-articular fracture
of base of 1st
metacarpal
characterized by
 intra-articular
comminution
 Epidemiology
 less common than
Bennett fracture
 Prognosis
 worse than Bennett

24.  Pathoanatomy
 deforming forces are the same as Bennett's
fracture
 volar fragment should have volar oblique
ligament attached
 shaft pulled dorsally
 typically the base is split into a volar and
dorsal fragment
 commonly called a 'Y' fracture
 often have more than two proximal fragments
Rolando Fracture

25.  Treatment
 Non-operative : immobilization
 indications
 for severe comminution, stable
 start early range of motion
Rolando Fracture

26.  Operative
 external fixation, CRPP
 indications
 for severe comminution, unstable
 technique
 can approximate large fragments with k-wires
 ORIF
 most common fixation method
 technique
 use t-plate or blade plate
 can use k-wires of fragments are too small for screw
purchase
Rolando Fracture

27.  Complications
 commonly results in post-traumatic
osteoarthritis
Rolando Fracture

28. Extra-articular fracture
 Extra-articular fracture of base of 1st
metacarpal
 can be transverse or oblique in nature

29.  Treatment
 nonoperative
 spica casting
 Indications : if joint is reduced and there is less
than 30 degrees of angulation
Extra-articular fracture

30.  Operative
 CRPP
 Indications : if reduction cannot be held to result
in less than 30 degrees of angulation
 outcome
 these fractures typically have the best outcome
Extra-articular fracture

31. Management
 Diagnosis : Rolando fracture of right wrist
 Plan of treatment
 On thumb spica cast
 Set OR for ORIF with miniplate