Conference Ext.ศิรดา 7 มีค.61

1. Case Conference
EXT. SIRADA CHUTCHUKIATKUL
PHRAMONGKUTKLAO COLLEGE OF MEDICINE

2. Case
• ผู้ป่วยหญิง อายุ 66 ปี
• สัญชาติไทย ศาสนาพุทธ
• Chief complaint : ล้ม 2 ชั่วโมงก่นมาโรงพยาบาล
• Present illness : 2 ชม. ก่อนมารพ. ผู้ป่วยสะดุดล้ม ใช้มือ
ซ้ายยันพื้นขณะล้ม จากนั้นมีอาการปวดที่ข้อมือซ้าย กระดก
ข้อมือไม่ได้ จึงมารพ.

3. Primary survey
• A : can talk, not tender along C-spine
• B : Spontaneous breathing, equal and clear breath sound both
lungs, CCT negative
• C : BP 126/76 mmHg, PR 88 bpm, no external bleeding
• D : E4V5M6, Pupil 3 mm RTLBE
• E : Tender and swelling at radial side of left wrist, Limit ROM of left
wrist due to pain, cap refill < 2 sec, Radial artery 2+, Left fingers full
ROM

4. Secondary survey
• A : ปฏิเสธประวัติแพ้ยา แพ้อาหาร
• M : ปฏิเสธยาที่ใช้ประจำ
• P : ปฏิเสธประวัติโรคประจำตัว
• L : NPO 12.00 น
• E : สะดุดล้ม ใช้มือซ้ายยันพื้น เจ็บบริเวณข้อมือซ้าย ไม่มีส่วน
อื่นกระแทก

5. Physical examination
• GA : Good consciousness
• HEENT : Not pale conjunctivae, no facial deformity, full ROM of neck, not tender
along c-spine
• Heart : Pulse full and regular, Normal S1S2, No murmur
• Lungs: trachea in midline, equal chest movement, equal and clear breath sound
both lungs, CCT negative
• Abdomen, No distension, Soft, Not tender
• Extremities : Tender and swelling at radial side of left wrist, Limit ROM of left wrist due
to pain, cap refill < 2 sec, Radial artery 2+, Pinprick sensation intact, Left fingers full
ROM
• Neurological exam: E4V5M6, Pupil 3 mm RTLBE, Motor grade V all

6. Investigation
• Film Left wrist AP, Lateral

8. Diagnosis
• Left distal end radius fracture (Fernandez type I)

9. Management
• Sedation : MO 5 mg IV stat
• Close reduction
• Short arm AP slab

11. Distal End Radius
Fracture

12. Distal end radius fracture
• Approximately 16% of all fractures treated by orthopaedic surgeons
• Three main peaks of fracture distribution:
• Children age 5-14
• Males under age 50 (High velocity)
• Females over the age of 40 years (Low velocity)
• Elderly (Mostly extra-articular)
• Young (Mostly intra-articular)
• Elderly patient risk factors : Decreased bone mineral density, female gender
and early menopause

13. Diagnosis
• History of mechanism of injury
• A visible deformity of the wrist is usually noted, with the hand most
commonly displaces in the dorsal direction.
• The acute shortening of the radius relative to the ulna may manifest as an
open wound palmarly and ulnarly where the intact ulna buttonholes
through the skin
• Movement of the hand and wrist are painful
• Adequate and accurate assessment of the neurovascular status of the
hand Is imperative. (Median nerve involvement – Carpal tunnel syndrome)

14. Diagnosis
• Evaluation of the injured joint, and a joint above and
below (ipsilateral elbow and shoulder joint)
• Radiographs of the injured wrist (PA & Lateral)
• Radiographs of other areas, if symptoms warrant

15. Anatomy
• Scaphoid and lunate fossa
• Ridge normally exists between these
two
• Sigmoid notch
• Second important articular surface
• Triangular fibrocartilage complex
(TFCC)
• Distal edge of radial to base of ulnar
styloid

17. Radiographic evaluations

19. Common Classifications
• Gartland & Werley
• Frykman (radiocarpal & radioulnar)
• AO
• Melone (impaction of lunate)
• Fernandez (mechanism)

26. Treatment
• Non-operative
• Operative

28. Indications for Closed Treatment
• Low-energy fracture
• Low-demand patient
• Medical co-morbidities
• Minimal displacement-acceptable
alignment

29. • Apply well-molded splint or cast, with
wrist in neutral to slight flexion
• Check X-ray to confirm the
acceptable reduction
• Follow up x-rays needed in 1-2weeks to
evaluate reduction
• Change to short arm cast after 2-3
weeks, continue until fracture healing.

30. Indications for Surgical Treatment
• Unstable
• Fernandez type II, IV, V and some case in I, III
• Lafontaine criteria >3 of 5 instability parameters
• Dorsal angulation >20 degree
• Dorsal comminuted
• Intra-articular radiocarpal fracture
• Ulnar fracture
• Age >60
• Secondary displacement after casting

31. Indications for Surgical Treatment
• Irreducible fracture
• Double die punch
• Displaced comminuted PM fragment
• Articular step off > 2mm
• Severe comminution
• Shortening > 5mm

32. Indications for Surgical Treatment
• Unacceptable alignment
• Radial inclination < 15 degree
• Shortening > 5 mm
• Dorsal tilt > 10 degree
• Volar tilt > 20 degree
• Articular step off or gap >2mm
• Open fracture

33. Indications for Surgical Treatment
• Associated injury
• Median Nerve Compression
• Distal Radioulnar Joint injury
• Carpal Ligament disruption
• Partial or complete tear scapholunate ligament
• Lunotriquetral ligaments tears 15%

34. THANK YOU