Interesting Case Orthopedics
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Transcript of Interesting Case Orthopedics
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Extern Thiwaporn P.
Interesting CaseOrthopedics
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◦Patient profile ผปวยชายไทย อาย 50 ป
◦Chief complaint : โดนมดฟนทเขาซาย 4 ชวโมงกอนมา
โรงพยาบาล
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Present illness4 ชวโมงกอนมาโรงพยาบาล ขณะกำาลงใช
มดพราฟนไมไผ เกดพลาดใชมดพราฟนเขา ทเขาซายของตนเอง เปนแผลฉดขาดลก เจบบรเวณ
แผล เดนแลวเจบทเขาซายมากจนทนเดนไมไหว จงไปทรพช. จากนนจงสงตวมารกษาตอทโรงพยาบาล
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Primary surveyA : Can speak, full ROM of neckB : Equal breath sound , CCT negativeC : BP 130/70 mmHg, P 88/minD : E4V5M6 pupil 3 mm RTLBEE : Lt.knee – Cut wound length 5 cm. wide 1 cm. expose patella with +/- stepping
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Secondary survey◦Allergy – ปฏเสธประวตแพยาแพอาหาร◦Medication – ปฏเสธยาทใชประจำา◦Past history – ปฏเสธโรคประจำาตว◦Last meal 05.00 PM◦Event – โดนมดฟนทเขาซาย
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Physical examination• Vital sign T 36.8 c, BP 130/70 mmHg, P
88/min, RR 18/min, O2sat 98%• General appearance : A Thai girl, crying• HEENT : not pale conjunctiva, anicteric sclera• Heart : no active precordium, no heaving, no
thrill, normal S1S2, no murmur• Lung : clear both lung• Abdomen : soft, not tender, no guarding• Extremities : cut wound deep to bone at
anterior left knee , limit ROM due to pain
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Differential diagnosis & Investigation
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Diagnosis Open fracture Left patella
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Fracture of Patella
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Investigation
◦Film Knee AP and Lateral◦Film Knee Merchant’s view
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Classification Modified Weissman
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TreatmentNon-operative management◦knee immobilized in extension
(brace or cylinder cast) and full weight bearing 6-8 week◦ indications◦ intact extensor mechanism (patient able to perform
straight leg raise)◦Non-displaced or minimally displaced fractures (displace or step off < 3 mm.)
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Operative managementORIF with tension band construct◦ indications
◦ preserve patella whenever possible ◦ extensor mechanism failure (unable to perform straight leg raise)◦ open fractures◦ fracture articular displacement >2mm◦ displaced patella fracture >3mm◦ patella sleeve fractures in children
partial patellectomy◦ indications
◦ comminuted superior or inferior pole fracture measuring <50% patellar height ONLY if ORIF is not possible
total patellectomy ◦ indications
◦ reserved for severe and extensive comminution not amenable to salvage
Treatment
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Complication
◦Late osteoarthritic change of patellofemoral joint◦Painful Retained Hardware
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Management ◦In this patient
◦Set OR for Debridement and ORIF
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Reference
◦ เอกสารประกอบการสอน นพ. อาร ตนาวล ภาควชาออรโธปดกส คณะแพทยศาสตรจฬาลงกรณมหาวทยาลย เรอง Injuries and affections of the lower extremities (Part II)
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Thank You for Your Attention : )