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





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 : -



• Chief complaint

– pain on the left shoulder and upper arm

•

Additional complaint – -



Universal Precaution

• Latex gloves



Primary Survey



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



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



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



Disability

GCS : E4M6V5 = 15, on arrival

Pupil : Isochoric, round, Ø 3mm/3mm

Light Reflex +/+Motoric strength: 5555 3344 (pain +)

5555 5555



Exposure

• Axillar temperature: 36.8oC



Secondary Survey



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



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 (-)



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




• 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




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 -/-




Cor

– Inspection : ictus cordis was not seen

– Palpation : ictus cordis was not palpable

– Percussion : was not examined

– Auscultation : heart sound: regular,

murmur (-), gallop (-)




Abdomen:

(examinations were done in sitting position)

– Inspection : flat

– Auscultation : bowel sound -

– Palpation : tenderness -

–

Percussion : was not examined




• Genital : was not examined

• Extremity : CRT< 2 seconds, warm,

range of movement +

+ +

movement strength

5555 3344

5555 5555



• Look: asymmetrical, deformity on left shoulder

• Feel: crepitation -, tenderness +, distal arterial pulse + on left

shoulder

• Move: AROM , pain + ; PROM , pain + on left shoulder



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



Diagnosis

• Closed fracture neck humerus sinistra Neer

two-part



Treatment in ER

• Arm sling

• Chest and shoulder xray



Chest & Shoulder xray 1 Sept 2011 at 20.18

• Closed fracture neck humerus two-part

• Osteoporosis

•

Cardiomegaly







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



Thank You



Proximal Humeral Fractures



Anatomy of the

humerus



Anatomy of the humerus



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



Physical Exam

• Shoulder

• Cervical spine

• Neurovascular examination

– Essential

– Performed with gentle motion

– 5-30% of complex proximal humerus fractures



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



Classification

• One-part fractures

• Two-part fractures

• Three-part fractures

• Four-part fractures

• Fracture-dislocation

•Head splitting and articular impressionfractures





One-part fractures

• Displacement <1 cmminimally displaced

• Surrounding soft tissue tend to hold the

fragments

• Immobilization and early functional exercises



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



C. Two-part surgical neck fractures

• Impacted & stable or displaced & unstable

• ORIF, percutaneous pin fixation



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



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





Fracture-dislocation

• Result of high-energy injuries

• Higher risk of neurovascular injury

• Posterior fracture-dislocations are often

missed



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





Complications

• Nonunion

• Malunion

• Avascular necrosis

• Arthrodesis



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



Malunion

• Associated with stiffness of the shoulder or

blocked range of motion

• Correcting the underlying restriction



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



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



Thank You

01 Sept 2011 Closed Fracture Neck Humerus Sinistra Neer Two Part Mrs.S 78 Dr.siti Dr.bonifacius SpB Sylviana

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