Extern conference suthida 15 พ.ย. 60

1. CONFERENCE
Ext. Suthida Maneemoon
Maharat Nakhon Ratchasima Hospital

2. Patient profile
• ผู้ป่วยชายไทยคู่ อายุ 38 ปี
• ภูมิลาเนาอาเภอโชคชัย จังหวัดนครราชสีมา
• สัญชาติไทย นับถือศาสนาพุทธ
• Cause of injury: ถูกฟันที่แขนขวา 3 ชม.ก่อนมารพ.
• เหตุเกิดเมื่อวันที่ 13 พ.ย. 60 เวลา 12.00น.

3. Present illness
• 3 ชม.ก่อนมารพ. ผู้ป่วยถูกฟันที่แขนขวาด้วยมีดตัดฟืน2ครั้ง
มีแผลฉีกขาดที่แขนขวาลึกถึงกระดูกแขนผิดรูป ขยับไม่ได้
เลือดไหลปริมาณมาก เจ้าหน้าที่นาส่งรพช. แล้วจึง referมา

4. Primary survey
• A : Can talk, not tender along c-spine
• B : Spontaneous breathing, equal breath sound, CCT -ve
• C : BP 78/48 mmHg, PR 92 bpm,
active bleeding from LW at Rt elbow
• D : E4V5M6 , pupil 2 mm RTLBE
• E : large LW 20cm deep to bone at Rt elbow

5. Adjunct Primary survey
• on O2 mask c bag
• NSS 1000 ml V load in 15 min (ได้ NSS จากรพช.มาแล้ว 3000 ml)
BP หลัง load 103/68
• Hct stat = 11
• G/M group O low titer 2 u v free flow
• Retain Foley, NG
• FAST –ve at 16.20
• Pressure dressing wound, on splint Rt arm&forarm

6. Secondary survey - History
• A : ปฏิเสธประวัติแพ้ยาแพ้อาหาร
• M : ปฏิเสธประวัติยาใช้ประจา
• P : ปฏิเสธประวัติโรคประจาตัว
• L : NPO 10.00
• E : ถูกมีดตัดฟืนฟันที่แขนขวา

7. Secondary survey – Examination(1)
• Head & Maxillofacial:
No wound, No facial deformities, no ecchymosis
• C-spine & Neck:
no wound, can move neck, C-spine not tender
• Chest:
Equal breath sounds, CCT -ve
• Abdomen & Pelvis:
no wound, bowel sound positive, soft, not tender

8. Secondary survey - Examination(2)
• Musculoskeletal:
Deformities of Rt arm&forarm ,
large laceration wound 20 cm deep to bone at Rt elbow(dorsum) with bone fracture,
Radial pulses 2+ both, capillary refill < 2 sec, sensory cannot evaluate due to pain
Rt wrist can flex but cannot extend, All finger can flex and extend
• Neurologic:
GCS: E4V5M6
CN: pupils 3 mm RTLBE, full EOM, no facial palsy
Motor: grade V all except Rt arm cannot evaluate
• Perineum/Rectum: no ecchymosis

12. Investigation

13. Investigation

14. Investigation

15. Diagnosis
• Open comminuted fracture at Rt distal humerus
• Open fracture both bone Rt forarm
Gustilo and Anderson classification IIIA

16. Management
• Resuscitation
• Pre-operative lab
• Set OR for Debridement + EF span elbow
• Antibiotic: cefazolin 1 g iv q6 hr c stat
• Consult trauma: R/o vascular injury

17. Post-operative
• Routine post operative care
• Pain control
• Serial Hct
• Antibiotic: Cefazolin 1 g iv q 6 hr
Gentamycin 240 mg iv OD x3 days
PGS 3million unit iv q 6 hr

18. Post-operative

19. OPEN FRACTURE
Extern Conference

20. Definition
• Open fracture is defined as one in which the fracture
fragments communicate with the environment through
a break in the skin

21. History in open fractures
• Mechanism of injury
– Date, time, type, method of impact, …
• Consciousness
• Size of wound
• Amount of bleeding
• Other injuries: often missed
• Anti-Tetanus status

22. Classification
“Gustilo and Anderson classification”
• Based on
1) Size of wound
2) Amount of soft tissue injury
3) Presence/absence of NV injury
4) Degree of contamination

23. Gustilo Classification

24. Gustilo Classification

25. Gustilo Grade I
• Low energy
• Simple fracture
• Skin open by fragment pressure
• Wound < 1 cm
• No / little contamination
www.orthopaedicsone.com/

26. Gustilo Grade II
• Higher energy
• Laceration > 1 cm
• No flap / No contusion
• Minimal contamination

27. Gustilo Grade IIIA
• High-energy,
• Adequate soft-tissue cover
• Contamination
• Comminution or segmental fracture

28. Gustilo Grade IIIB
• High-energy
• Extensive soft-tissue stripping
• Inadequate cover
• Massive contamination
• Soft tissue reconstruction is necessary

29. Gastilo Grade IIIC
• Associate vascular injury
• Requires vascular repair

30. Higher infection rate
Increased contamination
– Exposure to soil
– Exposure to water
– Exposure to fecal material
– Exposure to oral material
– Gross contamination
– Delay > 12 hours

31. Principal of treatment
• Antibiotic prophylaxis
• Urgent and proper wound and fracture debridement
• Stabilization of the fracture – External Fixation
• Early definitive wound cover

32. Management
• Gustilo I, II - Can treat by primary internal fixation
• Gustilo IIIA - Usually defer internal fixation until soft tissue condition allows
• Gustilo IIIB - External fixation
- Later, internal fixation
• Gustilo IIIC - Vascular repair is a priority
- External fixator

34. Complications
• Wound infection
• Osteomyelitis
• Non-union
• Tetanus infection
• Neurovascular injury
• Compartment syndrome

35. THANK YOU
Ext. Suthida Manemoon