Conference interesting case

Apiwan Prasitchai

“ Patient profile Thai female, 52 years old

Chief complaint Pain on left wrist for 3 hours

Present illness

3 hours prior to hospital, during the patient

took a back ridding for her grandchildren with

both hands on her back, she slipped with left

hand hit on the floor. Then her left wrist was

pain immediately without open wound.

No other pain on the body.

Personal history no underlying disease

no known drug and food allergy

no current medication

Past illness none

Physical examination

Primary survey – normal

Vital signs – BP 124/76mmHg

PR 82/min RR 18/min T 36.8C

Left wrist – swelling, mild deformity,

no wound, tender at distal radius

and distal ulnar, no piano key sign,

limit ROM, *neurovascular intact

Other extremities – no tenderness

Film left wrist

Diagnosis? Close fracture left distal radius and ulnat styloid

Initial management

Close reduction under anesthesia

short arm AP slab with three point fixation

Film left wrist

Distal end radius fracture Definition - fracture site <,= 1.5 inches from radiocarpal joint

Fernandez classification – base on mechanism of injury

Distal end radius fracture

Associated injuries

DRUJ injuries

Radial styloid fracture

Radiocarpal dislocation

Investigations

Film wrist AP and lateral

Treatment

Nonoperative – close reduction with immobilization

Operative

Close reduction

• Traction

• (Disimpaction)

• Volar flexion

• Ulnar deviation

Indication of surgery

Unstable Irreducible fracture Unacceptable alignment Open fracture Associated injury

unstable

• Fernandez type II, IV, V and some case in I, III

• Lafontaine criteria >=3/5

• Secondary displacement after casting

Lafontaine criteria

1. Dorsal angulation > 20

2. Ulnar Fx

3. Dorsal comminution

4. Intraarticular Fx

5. Age > 60 years

Irreducible Fx

• Double die punch

• Articular step off > 2 mm

• Shortening > 5 mm

• Severe comminution

Unacceptable alignment

• Articular step off > 2 mm

• Shortening > 5 mm

• Dorsal tilt > 10

• Volar tilt > 20

• Radial inclination <15

Advice

• ใส ่arm sling ให้ข้อมือสงูเหนือหวัใจ และเวลานอนให้วางบนหมอนเหนือระดบัหวัใจเชน่เดียวกนั เพ่ือลดบวม

• ถ้ามีอาการของ compartment syndrome ให้รีบมาพบแพทย์ทนัที

• six pack exercise of hand

• full ROM of other joint

Six pack exercise

Follow up

• change cast/slab

• clinical union evaluation

• prevent complication

• X-ray for radiologic union evaluation

References เอกสารประกอบการเรียนเวชปฏิบตัิทางออร์โธปิดิกส์

โรงพยาบาลนครราชสีมา

หนงัสือ Orthopaedic Trauma คณะแพทยศาสตร์มหาวิทยาลยัเชียงใหม ่

www.orthobullets.com

Thanks!

Any questions?