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1. EXTERN CONFERENCE Ext.Piraya Kantanawat 19 March 2018 2. ผู้หญิง 67 ปี ตกจากม้านั่ง ศอกผิดรูป…
  • 1. EXTERN CONFERENCE Ext.Piraya Kantanawat 19 March 2018
  • 2. ผู้หญิง 67 ปี ตกจากม้านั่ง ศอกผิดรูป 7ชั่วโมงก่อนมา รพ. Chief complaint
  • 3. ผู้ป่วยหญิง 67 ปี โรคประจำตัว HT controlled ภูมิลำเนำ ครบุรี นครรำชสีมำ Cause of injury : ล้มจำกม้ำนั่ง แขนซ้ำยกระแทกพื้น เกิดเหตุวันที่ 14 มีนำคม 2561 เวลำ 14.00น. ไปรพช.ครบุรี 19.20น มำรพ.มหำรำช 21.19น
  • 4. PRESENT ILLNESS 7 ชั่วโมงก่อนมำรพ. ขณะยืนบนม้ำนั่งสูง 50cm. ลูกมะพร้ำวตกใส่ตัว เสียหลักล้ม จำกม้ำนั่ง แขนซ้ำยกระแทกพื้น หลังจำก นั้นศอกซ้ำยผิดรูป งอศอกไม่ได้ ปวดแขน ซ้ำย ไม่มีชำปลำยมือ ศีรษะไม่กระแทกพื้น
  • 5. Primary survey A-patent can talk ,post neck not tender B-clear equally both lungs, CCT negative C-BP147/68mmHg ,PR 82bpm full D- E4V5M6 pupil 3mmRTLBE E- deformity Lt.elbow, tender and limit ROM Lt.elbow due to pain , intact sensory and ulna/radial/median n. Motor, radial pulse 2+
  • 6. INVESTIGATION Film Lt elbow AP,Lat จำกรพช
  • 7. MANAGEMENT AT ER Close reduction with Posterior Long arm slab in elbow flexion 90° and supination position
  • 9. ELBOW DISLOCATION Incidence: elbow dislocations are the most common major joint dislocation second to the shoulder most common dislocated joint in children account for 10-25% of injuries to the elbow posterolateral is the most common type of dislocation (80%)
  • 10. ELBOW DISLOCATION Mechanism: most common mechanism is fall onto outstretched arm ❖ Posterior: elbow hyperextension, arm abduction, and forearm supination together cause movement of the olecranon posteriorly (ex: falling onto an extended arm) Anterior: direct force to posterior forearm while elbow is in flexion
  • 11. ELBOW DISLOCATION Symptoms • pain and swelling Physical exam • important to assess • the status of the skin - evaluate for open injuries • presence of compartment syndrome • neurovascular status : esp ulna n. • status of wrist and shoulder concomitant injuries occur in 10-15% of elbow dislocations
  • 12. FINDINGS
  • 13. ELBOW DISLOCATION Classification Simple vs complex: ❖ Simple- dislocation ❖ Complex- dislocation with fracture terrible triad injury : elbow dislocation associated with a LUCL tear, radial head fracture, and coronoid tip fracture radial head fractures occur in up to 10% of elbow dislocations Displacement of ulna relative to humerus ❖ Posterior, posterolateral, posteromedial, lateral, medial, anterior
  • 14. ELBOW DISLOCATION Investigation ❖ film elbow AP, lateral ❖ Oblique view to assess periarticular fx
  • 15. TREATMENT closed reduction and splinting at least 90° for 5- 10 days, early therapy ❑ indications ➢ acute simple stable dislocations recurrent instability after simple dislocations is rare (<1-2% of dislocations) Non-operative
  • 16. TREATMENT ❖ Open reduction, capsular release, and dynamic hinged elbow fixator ❑ indications ➢ chronic dislocations ❑ postoperative ➢ hinged external fixator indicated in chronic dislocation to protect the reconstruction and allow early range of motion Operative ❖ORIF (coronoid, radial head, olecranon), LCL repair, +/- MCL repair ❑indications ➢ acute complex elbow dislocations ➢ persistent instability after reduction (elbow requires >50-60° to maintain reduction) ➢ reduction cannot be performed closed (often due to entrapped soft tissue or osteochondral fragments)
  • 17. REDUCTION •Parvin’s method: patient lies prone with entire upper extremity hanging off the bed, downward traction is applied to the wrist for a few minutes—> olecranon slips distally, arm is then lifted gently (Method A) •Meyn & Quigley method: forearm hangs off of bed, gentle downward traction is applied to wrist, olecranon is guided with opposite hand (Method B)
  • 18. REDUCTION assess post reduction stability elbow is often unstable in extension elbow is often unstable to valgus stress : test by stressing elbow with forearm in pronation to lock the lateral side
  • 19. TAKE HOME POINTS • Three complications of elbow dislocations that must be appreciated and require operative management: 1.neurovascular compromise 2.associated fractures fractures • Simple, uncomplicated dislocations can be treated with closed reduction, splinting and orthopedic follow up in 1-2 weeks
  • 20. REFERENCES w-dislocation
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