Extern case conferenceTHANYAPORN WISITPHORNANAN 5402064

case

Patient profile ผปวยชายไทย อาย 15 ป

Chief complaint ถกหนเจยบาดเทาซาย 7 ชม.กอนมาโรง

พยาบาล

Present illness

7 ชม. กอนมาโรงพยาบาล ขณะทำางาน ถกหน เจยหลนใสเทา บาดนวชเทาขางซายเปนแผล

ลก มอาการชา ปวด ขยบนวชเทาไมได ไมมบาดแผลบรเวณอน

Past History

No underlying disease No current medicationNo drug allergy

Physical examination

ABCD – OK GA – A Thai man , Alert , good consciousness , well

co-operative V/S – Temp 36.7 HR 67 bpm BP 131/87 RR 16 /min

HEENT – not pale conjunctivae , anicteric sclerae Lung – clear , equal breath sound both lungs Heart – normal s1 s2 , no murmur

Physical examination

Laceration wound 0.5 x 2 cm.Deep to bone No active bleedingCapillary refill < 2 secLimit ROM

Film

Left foot AP

Film

Left foot Oblique

middle phalanx of 2nd toe of Left foot fracture

Impression

Open Fracture middle phalanx of 2nd toe of Left foot

R/O tear tendon

Toe Fracture

Anatomy

Management of Toe fracture

First toe• role in weight bearing, balance, and pedal

motion• require referral much more often than other

toe fractures

Lessor toe

Lessor toe fracture Treatment

‘Buddy taping’ 3 weeksPain control Acute subungual hematoma

decompression เจาะเลบ release pressure

Lessor toe fracture

 referral is recommended for patients with open fractures, fracture-dislocations  displaced intra-articular fractures, children with fractures involving the physis, except nondisplaced Salter-Harris type I and type II

Open Fracture

Gustilo Classification

Management

initial trauma survey and resuscitation IV antibiotics tetanus prophylaxis Dressing - remove gross debris , irrigation Immobilization Set OR for Aggressive debridement and irrigation

Antibiotic Treatment

Gustilo Type I and II 1st generation cephalosporin for gram positive

Gustilo Type III 1st generation cephalosporin for gram positive Aminoglycoside (such as gentamicin) for gram negative  +- Penicillin for anaerobe in farm injuries or possible

bowel contamination

Management in this patient

NPO , 5%DN/2 1000 ml iv 80 ml/h Cefazolin 1 g iv q 6 h Tetanus toxoid 1 course Irrigation , dressing wound Immobilization MO 4 mg iv Set OR

Operation

Finding

• Open fracture middle phalanx of left 2nd toe

• Partial tear EDL tendon of left 2nd toe

Operation

Excision debridement with K-wire fixation with tendon repair