Case conference ศุภกฤษ อัศวสดุสาคร

Patient profile• เด็กหญิง 7 ปี• ขีร่ถจกัรยานล้มเอง 3 ชัว่โมงก่อนมา รพ. ใชม้อืยนัพื้น

เจบ็แขนซา้ยทันที แขนซา้ยผิดรูป ไมม่สีลบ ไมม่อีาเจยีน

Primary survey• A : can speak, can move neck• B : CCT negative, equal BS• C : vital sign stable• D : E4V5M6, pupils 3 mm RTLBE• E : no external wound,

Secondary survey• A : ไมแ่พย้า แพอ้าหาร• M : no medication• P : no U/D• L : 6 hr• E : ขีจ่กัรยานล้มเองบนพื้นคอนกรตี

Physical examination• Left arm : no external wound, deformities, tender,

limit ROM due to pain, swelling• Neurovascular intact

Investigation

Diagnosis“Closed fracture both bone left forearm”

Fracture both bone forearm in children

Anatomy

Mechanism of injury• Fall on out stretched arm

Type of fracture• Green stick• Complete fracture

Treatment• Non operative• Operative

Non operative• Close reduction • Immobilization

Acceptable reduction alignment for pediatricinitial considerations: - angular / rotational deformity: (growth will not correct rotational deformity) - age - distance from physis - direction of angulation - amount of deformity

Bayonette apposition• there was no deviation of radius and ulna toward

each other.• there was no encroachment of the interosseous

space.• pt is less than 10 yrs of age.

Age< 6 year 6-10 year > 12 year

Angulation < 15° < 10° 0°

Rotation < 5° 0° 0°

Bayonet apposition

accept accept -

Displaced Distal Third Frx: angulation up to 20-25 deg during first ten years is OK

OperativeIndication • Open fracture• Unacceptable alignment after reduction more than

twice• Compartment syndrome• Neurovascular compromise• Refracture

Operation • Intramedullary fixation with flexible

nails or K-wires•ORIF with plates and screws •Percutaneous K-wire fixation

Follow up• weekly radiographs for first 3-4 weeks to monitor

reduction• casting for 6-12 weeks total

Complication •Malunion• Premature or partial physeal arrest• Cross-union of the radius and ulna•Nonunion • Compartment syndrome• Infection•Neurovascular injury

Thank you