Case conference

Ext.Atthaya Raksuan

Case• ผปวยเดกหญงไทย อาย 12 ป ภมลำาเนา

อ.ปกธงชย จ.นครราชสมา• สทธการรกษา บตรทอง • อาชพ นกเรยนชนมธยมศกษาตอนตน• ประวตไดจากผปวยและเวชระเบยน ความนาเชอ

ถอมาก

Chief complaint

• ปวดบวมแขนขวา 5 ชวโมง กอนมาโรงพยาบาล

Present illness

• 5 ชวโมงกอนมาโรงพยาบาล ผปวยใหประวต วาขณะวงเลนกบเพอน ลม แขนขวากระแทกพน

หลงจากนนมแขนขางขวาผดรป ปวดเจบ บวม มากขน ไมมแผล ไมมศรษะกระแทก ไมหมดสต

ไมมอาเจยน ไมมบาดเจบบรเวณอน

Primary survey

• A : Can talk, no midline tenderness along c-spine• B : Negative chest compression test, trachea in

midline, equal chest movement and equal breath sound both lungs

• C : BP 125/74 PR 102 /min • D : E4V5M6, pupils 3 mm RTLBE• E : Right forearm swelling, no wound, sensory

intact, capillary refill< 2 sec, passive stretch test negative

Secondary surveyA : no food and drug allergyM : no current medicationP: no underlying diseaseL : last meal 3 hr. PTA E : ขณะวงเลนกบเพอน หกลม แขนขวากระแทกพน

มอาการปวดบวมแขนขวา ไมมบาดเจบทอน

Investigation

Film right forearm AP view

Film right forearm lateral view

• Film : minimally displaced fracture midshaft both bone of right forearm

• Diagnosis : Close fracture both bone right forearm

InvestigationCBC• Hct 33.3 %• Hb 10.4 g/dL• WBC 11,100ul• PMN 84.3 %• Lymph 11.4 %• Mono 4.1 %• Eo 0.0 %• Ba 0.2 %• Plt. 194,000 ul• MCV 68.6 fL• RDW 15.9 fL

• Anti HIV : negative

Management

– Pethidine 40 mg IV stat– Close reduction and apply long arm AP slab right

arm– Admit– Observe compartment syndrome

Film right forearm AP/lat ( หลงใส slab)

Compartment syndrome

Definition

- Elevated tissue pressure within a closed fascial space

- Ruduces tissue perfusion – ischemia- Results in cell death – necrosis

True Orthopaedic Emergency

Pathophysiology

Etiology

• Fracture of a long bone (Supracondylar,

humerus, forearm, hand, tibia and foot)

Etiology

Bleeding within the compartment:

- Post operative - Closed reduction

Etiology

• Tight cast

Etiology

Severe bruised muscle (even if there is no

fracture)

• Don’t take contusion lightly

Signs and symptoms5 P’s1. Pain : The earliest sign 2. Paraesthesia 3. Pallor4. Paralysis5. Pulselessness

Signs : 6. tight swelling7. Loss of strength8. Loss of sensation9. Blister

(presence of a pulse does not exclude the diagnosis)

The earliest sign : PAIN

• Pain that out of proportion to the injury• Describe as ‘bursting’ sensation• Pain that is not responsive to the normal

dosage of pain medication• Severe pain with passive stretch

Diagnosis

• Passive stretching of fingers or toes (muscle stretch)will lead to severe pain (diagnostic sign)

• Compartment syndrome is a clinical diagnosis• Never wait for signs of ischemia (5 Ps) :

irreversible damage

For obtunded, intubated, or unreliable patients who have a swollen extremity but who otherwise cannot be evaluated

Whiteside maneuver

• Wick hand held instrument

• Stryker STIC Monitor

MANAGEMENT

Non surgical management:

• Remove any tight bandage or soaked dressing

• Cast should be removed completely

• Elevation

MANAGEMENT

Surgical management:

FASCIOTOMY

Open skin and fascia down to a compartment

Close skin by secondary sutures after oedema subsides

It may need skin graft

Complications• Acute renal failure secondary to

rhabdomyolysis• Disseminated intravascular coagulation• Volkmann’s contracture (where infarcted

muscle is replaced by inelastic fibrous tissue)• Amputation

• Compartment syndrome is a serious syndrome, Which needs to be diagnosed early.

• Palpable pulse doesn’t exclude compartment syndrome

• If diagnosis and fasciotomy were done within 24 hrs, the prognosis is good.

• If delayed, complications will develop.The earlier you diagnose, the safer you are

If not sure Admit patient for Close monitoring

Take home message!!

Thank you for your attention…