Nithit case discussion

Extern conference

BY NITHIT SEMSAWAT

PI 5422054

ผปวยหญงไทยคอาย 58 ป ภมล าเนา อ าเภอเมอง จงหวด นครราชสมา

สทธประกนสขภาพถวนหนา

Chief complaint

ลมไหลซายกระแทกพน 3 วน PTA

Primary survey

• A : can talk , no cervical spine tenderness , full ROM of neck

• B : equal breath sound , no adventitious sound, CCT neg

• C : BP 119 / 76 mmhg , PR 98/min , RR 20 / min

, T 36 C , no visible site of active bleeding.

• D : E4V5M6, pupil 3 mm RTLBE

• E : No External wound

Secondary survey

• A : no drug allergy

• M : no current medication

• P : no underlying disease

• L : last meal 4 hr PTA

• E : 3 day PTA ลนหกลมไหลซายกระแทกพน เจบแขนซาย ยกแขนไดเลกนอยเนองจากปวด บวมเลกนอย ไมมแผลดานนอก ไมมอาการชาทไหล ไมมเลอดออก ไมมอาการเจบบรเวณอน ไมสลบ ขยบขอมอไดปกต

Physical examination

• Vital signs : BP 119 / 76 mmHg , PR 98/min , RR 20 / min , T 36 C

• General appearance : A Thai women good consciousness, well co operative

• HEENT : not pale, no jaundice

• Lung : clear , equal breath sound both

• CVS : normal s1s2, no murmur

• Abdomen : soft not tender

• Neuro : E4V5M6 , orientated to time place person

Extremieties : Left shoulder

• Tenderness, mild swelling, limited ROM due to pain, no deformity, no ecchymosis at left shoulder , no numbness at deltoid area

• Brachial pulses 2+

• Radial pulse 2+ • No wrist drop

Investigation : Film left shoulder AP, Transcapular

Diagnosis

CFX left humeral neck

Management

• On Arm sling

• F/U 2 wk + Film left shoulder AP, Transcapular

• Home medication

– Paracetamol [500] 1 tab oral prn for pain q 6 hr

– Tramol [50] 1*3 oral prn for pain

Fracture Proximal

Humerus

Outlines

• Epidemiology and risk factors

• Signs and symptoms

• Physical Examination

• Radiographic findings

• Neer classification

• Indication for referral

• Follow-up care

• Return to sport or work

Epidemiology and risk factors

• Incidence 4-5 % of all fractures

• Incidence increases with age

– > 70 % occurring in Pt. > 60 yr.

• 3-4 times more common in females

• Risk factors

– Frequent falls

– Low bone density

Signs and symptoms

• Shoulder pain that increases with shoulder movement

• Swelling and ecchymosis

• Shoulder deformities

Physical Examination

• No specific examination tests for diagnosis • Typically have focal tenderness at proximal

humerus • Neurovasucular injury

– Axillary nerve • Deltoid m. weakness • Decrease sensation of mid-deltoid region

– Suprascapular nerve • Supraspinatous and infraspinatous m. weakness

• Vasucular injury – Circumflex artery

Radiographic findings

• Film shoulder AP , transcapular

• CT with three dimensional reconstructions [if Plain film can’t diagnostic]

Film shoulder AP

Film Transcapular view

Fracture patterns : Neer classification

• Non – displace VS Displaced

1. Displaced > 1 cm

2. Angulation > 45 degrees

• Fracture classified

– One-part Fracture

– Two-part Fracture

– Three-part Fracture

– Four-part Fracture

Displaced

Non-Displaced

Displaced

Indication for referral

• 80 % are non-displace or minimally displace – Can conservative at primary care clinicians

• Displaced [2-4 part fractures]: need surgery – Refer to orthopedic surgeon for evaluation

- Osteosynthesis - Percutaneous pinning

- ORIF - Hemiarthroplasty

• Emergency referral – all nerve and vascular injuries – Fracture dislocation

Initial treatment

• Immobilization – Standard sling : impact fracture – Collar and cuff sling

• Reduction of minimally displaced fragments

– Swathes : use in shoulder unstable • Pain control

• Ice : reduce pain and swelling • Pain control medication • Close reduction of fracture fragments is not

recommended – Because several muscles have insertions on the proximal

humerus

Follow-up care

• Total healing is typically 6-12 wks

• Early callus formation usually occurs a 4-6 wks

• Duration of immobilization – 1-2 wks initiated ROM exercises

Follow-up care: Reevaluation

• 7-14 days Reevaluation for significant displacement

• If pain is well controlled and no displacement fragments

– Pendulum exercises : decrease loss of shoulder motion

– Isometric strengthening exercises for the biceps and triceps

Pendulum exercises Isometric strengthening exercises

Follow-up care : Subsequent visits

• 2 - 4 wks after surgery

– Encourage to discontinue their sling

– Passive range of motion exercise of the elbow and shoulder : Twice daily

• Pendulum exercise

• Wall climbing exercise

• Consult PT for passive ROM if necessary

• Serial follow up q 2-4 wks for evaluation and improve range of motion

Wall climbing exercise

Follow-up care : Complications

• Loss of shoulder mobility : most common

• Neurovascular injury

– Circumflex artery

– Axillary or suprascapular nerve

– Rotator cuff tear [if dislocation of humeral head ]

• Osteonecrosis of Humeral head [uncommon]

Return to sport or work

• Work : 3 wks after proximal humerus fracture

– Not full use of the affected arm

– 8-12 wks if jobs includes two-handed labor

• Sports

– Adequate range of motion

– Strength as well as stable callus formation on radiographs

Take home message

• Non displace fracture

– Conservative

– Early ROM exercise

• Displace fracture

– Refer to orthopedic surgeon for evaluation