01 sept 2011 closed fracture neck humerus sinistra neer two part mrs.s 78 dr.siti dr.bonifacius spb...
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8/4/2019 01 Sept 2011 Closed Fracture Neck Humerus Sinistra Neer Two Part Mrs.S 78 Dr.siti Dr.bonifacius SpB Sylviana
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EMERGENCY CASEREPORT
Thursday, September 1, 2011ER Physician: dr. Siti
Supervisor: dr. Bonifacius Sp.B
Sylviana Hamid
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Patient’s Identity
• Name : Mrs. S
• Age : 78 years old
• Time of the event : Thursday, September 1, 2011
at 16.00
• Time of admission : Thursday, September 1, 2011
at 20.00
•
Sent by : car• Prehospital treatment : -
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• Chief complaint
– pain on the left shoulder and upper arm
•
Additional complaint – -
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Universal Precaution
• Latex gloves
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Primary Survey
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Airway with Cervical Control
• Cervical Immobilization:1. Collar : -2. LSB : -
• Airway Assessment:There is no obstruction. Snoring -, gurgling -.Patient can speak clearly.
Airway clear: 20.02
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Breathing and Ventilation
• RR: 28 x/minute
• Look: spontaneous breathing, deformities – , retraction –
symmetrical hemithorax movement, cyanosis -,difficulty in breathing -
• Feel: air blown from nose
• Listen: breath sound was heard, vesiculair, rhonchi -/-,
wheezing -/-
Breathing clear: 20.05
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Circulation
Assessment:
Pulse : 84 x/minute
BP : 140/70 mmHg
Skin : CRT< 2 seconds, no pallor, nocyanosis, hands and feet are warm
Circulation clear : 20.08
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Disability
GCS : E4M6V5 = 15, on arrival
Pupil : Isochoric, round, Ø 3mm/3mm
Light Reflex +/+Motoric strength: 5555 3344 (pain +)
5555 5555
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Exposure
• Axillar temperature: 36.8oC
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Secondary Survey
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History Taking
• Allergy : denied
• Medication : was given two kinds of medication after hypertensionwas diagnosed
• Past illness : hypertension, which is known2 months ago. Medications areunknown
• Last meal : about 5 hours before admission
• Event : accident, fell on the floor
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History of Present Illness
• About 4 hours before admission, the patient had an
accident. She fell on the floor. She fell with her left
side hit the floor. Her head did not hit the floor. After
the accident, she felt pain on her left shoulder andupper arm, especially when she tried to move her
left arm. She was brought to an internist who then
referred her to Atma Jaya hospital.
• Syncope (-), vomitting (-), headache (-)
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Physical Examination
• General condition : looked in pain
• Consciousness : GCS 15, E4M6V5
•
BP : 140/70 mmHg• Pulse : 84 x/minute
• RR : 28 x/minute
• Temperature : 36.8 0 C
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Physical Examination
• Head : deformities -
• Face : deformities -
• Eyes : conjunctiva anemic -/- ,
sclerae icteric -/- , pupil isochoric,
round, diameter 3 mm/3 mm,
light reflex + /+
• Neck : lymph nodes were not palpable
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Physical Examination
Thorax :(examinations were done in sitting position)
Pulmo – Inspection : symmetric in static and dynamic
– Palpation : stem fremitus equal on both side
– Percussion : was not examined
– Auscultation : vesiculair, rhonchi -/- ,wheezing -/-
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Physical Examination
Cor
– Inspection : ictus cordis was not seen
– Palpation : ictus cordis was not palpable
– Percussion : was not examined
– Auscultation : heart sound: regular,
murmur (-), gallop (-)
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Physical Examination
Abdomen:
(examinations were done in sitting position)
– Inspection : flat
– Auscultation : bowel sound -
– Palpation : tenderness -
–
Percussion : was not examined
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Physical Examination
• Genital : was not examined
• Extremity : CRT< 2 seconds, warm,
range of movement +
+ +
movement strength
5555 3344
5555 5555
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• Look: asymmetrical, deformity on left shoulder
• Feel: crepitation -, tenderness +, distal arterial pulse + on left
shoulder
• Move: AROM , pain + ; PROM , pain + on left shoulder
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Observation20.00 20.15 20.45
Airway clear clear clear
Breathing adequate adequate adequate
RR (times/min) 28 28 24
Circulation
Pulse (times/min) 84 80 80
BP (mmHg) 140/70 140/70 130/70
GCS 15 15 15
Temperature 36.80 C 370 C 370 C
Arrival Just before the xray
was taken
Just before the pt
left Atma Jaya
hospital
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Diagnosis
• Closed fracture neck humerus sinistra Neer
two-part
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Treatment in ER
• Arm sling
• Chest and shoulder xray
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Chest & Shoulder xray 1 Sept 2011 at 20.18
• Closed fracture neck humerus two-part
• Osteoporosis
•
Cardiomegaly
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Treatment
• Admitted to surgery ward
• Advice: ORIF PHP + screw
• Farmadol® (Paracetamol) 3 g/day given 3 x 1 g IV
• Acran® (Ranitidine) 100 mg/day given 2 x 50 mg IV
• Routine laboratory test, bleeding time, clotting time
• Chest x-ray
• ECG
• Consult to the internal medicine department
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Thank You
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Proximal Humeral Fractures
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Anatomy of the
humerus
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Anatomy of the humerus
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Overview
• Classified according to the patterns of
displacement of the four major segments
• Displaced any major segment is displaced
more than 1 cm or angulated greater than
45 degrees
• 4-5% of all fractures
• Older patientsminor trauma + decreased
bone density
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Physical Exam
• Shoulder
• Cervical spine
• Neurovascular examination
– Essential
– Performed with gentle motion
– 5-30% of complex proximal humerus fractures
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Imaging
• Radiographs – Trauma series three views: anteroposterior, lateral,
emergency axillary view
• CT scan – Delineates the degree of displacement
• MRI – Soft tissue injury
– Early assesment of osteonecrosis after trauma
• Arteriography and venography – When a vascular injury is suspected
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Classification
• One-part fractures
• Two-part fractures
• Three-part fractures
• Four-part fractures
• Fracture-dislocation
•Head splitting and articular impressionfractures
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One-part fractures
• Displacement <1 cmminimally displaced
• Surrounding soft tissue tend to hold the
fragments
• Immobilization and early functional exercises
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Two-part fractures
A. Two-part lesser tuberosity fractures
– Posterior glenohumeral dislocation
– ORIF
B. Two-part greater tuberosity fractures
– Anterior glenohumeral dislocation, longitudinal
tears of the rotator cuff
– ORIF, repair of the rotator cuff
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C. Two-part surgical neck fractures
• Impacted & stable or displaced & unstable
• ORIF, percutaneous pin fixation
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Three-part fractures
• Displacement of 3 segments: humeral head,
humeral shaft, one tuberosity
• ORIF using tension band wiring that
incorporates the rotator cuff tendon,
prosthetic replacement elderly patients
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Four-part fractures
• Each major segment is displaced
• Humeral head is devoid of of soft tissue
osteonecrosis
• ORIF young patients
• Prosthetic replacement
– Early passive motion
– Active motion should be delayed for 8-12 weeks
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Fracture-dislocation
• Result of high-energy injuries
• Higher risk of neurovascular injury
• Posterior fracture-dislocations are often
missed
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Head-splitting and articular
impression fractures
• Associated with chronic dislocations
• Prosthetic replacement, ORIF
• Articular surface defects <20% tend to bestable after immobilization
• Defects >40% require soft tissue transfers into
the defect or prosthetic replacement
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Complications
• Nonunion
• Malunion
• Avascular necrosis
• Arthrodesis
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Nonunion
• Risk factors: – Inadequate fixation or immobilization
– Traction at the fracture site
– Soft tissue interposition – Osteonecrosis
• Most commonly in two-part surgical neckfracture
• Reduction and fixation, prostheticreplacement
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Malunion
• Associated with stiffness of the shoulder or
blocked range of motion
• Correcting the underlying restriction
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Avascular necrosis
• Usually occurs after three- or four-part
fractures treated either closed or open in
which the blood supply to the humeral head is
compromised
• Arcuate artery
• Treatment is based
on the presentation
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Arthrodesis
• Indications – Young patient with nonfunctioning shoulder
musculature
–
Prior deep infection – Loss of cartilage
– Severe pain refractor to conservative treatment
• Optimal position for shoulder arthrodesis: 20degrees of flexion, 30 degrees of abduction,40 degrees of internal rotation