Case conference fx bb
Transcript of Case conference fx bb
Case Conference10/10/2016
Ext. Natsuda Tatu Faculty of Medicine, Chiangmai university
Case scenario
• Identification data: ผู้ป่วยชายไทยคู่ อายุ 77 ปี ปัจจุบนัไมไ่ด้ประกอบ อาชพี
ภมูลิำาเนาอำาเภอเมอืง จงัหวดันครราชสมีา• Admission date: 7/10/2559• Source of data: ผู้ป่วย, ญาติ, และบนัทึกทางการแพทย์• Reliability: มาก• Chief complaint: ล่ืนล้ม ปวดขาซา้ย 3 ชัว่โมงก่อนมาโรงพยาบาล
Primary survey
• A: can talk, no stridor• B: clear & equal breath sound both lung• C: BP 188/94 mmHg, PR 70 bpm, no active bleeding• D: E4V5M6, pupil 3 mm RTLBE
Secondary survey
• GA: An elderly Thai man with normal consciousness• V/S: BP 188/96 mmHg PR 70 bpm RR 18/min BT 36.6• HEENT: no pale conjunctiva, no jx, no cervical LN• Heart: regular rhythm, no murmur• Lung: CCT neg, clear & equal BS both lung• Abdomen: soft, no tenderness, normoactive bowel sound• Pelvic: no contusion, no wound, PCT neg• Extremity: affected part Left leg
Affected part
• Left leg:• Swelling at lower leg• Tenderness at lower leg• Can perform ankle dorsiflexion
and plantarflexion• Dorsalis pedis 2+• Sensory intact
Secondary survey
• Allergy: no food and drug allergy• Medication: - Atenolol (50) 1x1 PO pc
- Doxazosin (2) 1xhs• Past illness: HT, BPH, HNP• Last meal: -• Event: 3 ชัว่โมงก่อนมาโรงพยาบาล (16.00 น.) ขณะเดินโดยใช้ walker
ล่ืนล้มเอง ไมไ่ด้วูบ หรอือ่อนแรงก่อนจะล้มลง ขาซา้ยกระแทกพื้นปูน มอีาการ ปวดและบวมขึ้นมาทันที ขาซา้ยไมส่ามารถรบันำ้าหนักได้ ไมม่แีผลเปิด ศีรษะไม่
กระแทกพื้น จำาเหตกุารณ์ได้ จงึไปโรงพยาบาล ป. แพทย์ ได้ x-ray และดามไว้ก่อนสง่มารกัษาต่อท่ีโรงพยาบาลมหาราชนครราชสมีา
InvestigationFilm leg AP, Lat
Film ankle AP, Lat, mortise
Diagnosis
• Closed fracture both bone left leg
Management at ER
• Close reduction• On posterior long leg slab
Tibia and fibular shaft fracturesFracture both bone
Introduction
• Tibia and fibular fractures are relatively common• Bimodal distribution:
• > 50 yr low energy, spiral pattern• < 30 yr high energy, transverse and comminuted fracture
• Mechanism of injury• Low energy: Fall from standing height, sporting injury• High energy: Vehicular trauma (pedestrian > MC > motor vehicle
crash), direct blow, gunshot, fall from height
Assessment
• Mechanism of injury• Associated injuries• Imaging and other diagnostic studies• Classifications
• Fracture configuration• Soft tissue involvement
Mechanism of injury
• Low-energy• Fall from standing height• Sporting injury
• High-energy• Vehicular trauma (Pedestrians > MC > Car crash)• Assault (Direct blow, Gunshot wound)• Fall from height
• Usually open fracture (≥ Gustilo IIIB)
Associated injuries
• Compartment syndrome• Ankle injuries• Floating knee injuries• Fracture extension into tibia plateau• Knee ligamentous injuries• Proximal tibiofibular joint dislocation
Imaging & other diagnostic studies
• X-ray • AP and lateral view, include entire length of tibia & fibular
• CT, MRI• If concern pathologic bone lesion
• Minimal energy mechanism• History of malignancy• Antecedent pain• Irregular appearance on bone x-ray
AO/OTA classification
• Type A Simple fracture
Spiral
AO/OTA classification
• Type A Simple fracture
Oblique>30 degree
AO/OTA classification
• Type A Simple fracture
Transverse
AO/OTA classification
• Type B Wedge fracture
Spiral
AO/OTA classification
• Type B Wedge fracture
Bending
AO/OTA classification
• Type B Wedge fracture
Fragmented
AO/OTA classification
• Type C Complex fracture
Spiral
AO/OTA classification
• Type C Complex fracture
Segmental
AO/OTA classification
• Type C Complex fracture
Irregular
Associated soft tissue injury classification• Useful for determined proper management of tibial and
fibular fx• For closed fracture
• Tscherne classification• For open fracture
• Gustilo classification
Tscherne classification
Simple fx withLittle/no soft tissue injury
Mild-mod fx configSuperficial abrasion
Tscherne classification
Moderately severe fx configDeep contamination c local skin/muscle contusion
Severe fxextensive contusion or crushing of skin or destruction of muscle
Gustilo classification
Anatomy
Treatment option
• Non-operative treatment• Closed reduction• Immobilization cast, slab• Rehabilitation
• Operative treatment• Open reduction/close reduction• Immobilization Intramedullary nail, Plate & screw
Non-operative treatment
• Indications:• Adequate alignment, length, and rotation in a splint or cast• Soft tissue cannot tolerate cast• High anesthetics risk• Patient refused operative treatment
• Contraindication:• Inadequate alignment, length, and rotation after application splint
or cast• Open fracture• Arterial injury• High risk of develop compartment syndrome
Non-operative fixation
• Long leg cast • Partial weight bearing with crutches as soon as tolerated• Full weight bearing at 2nd – 4th wk after injury
• Patella tendon-bearing cast• At 4th – 6th wk after injury
• Average time to union about 16 weeks
Long leg cast
Patella tendon-bearing cast
Operative treatment
• Indications:• Failure to obtain adequate close reduction• Open fracture• Vascular injury• Massive soft tissue damage• Patient who too unreliable for closed treatment• Patient prefer not to have a cast
• Better outcome than non-operative treatment
Operative fixation
• Intramedullary nail• Interlocking nail*• Flexible IM nail
• Plate• External fixator
Intramedullary nail
Plate
Complications
Thank you