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ospe. KWH. Case 1. M/38 Right shoulder contusion after S/F PE: tenderness and swelling over his right upper chest . No skin impingement and no external wound found. No distal neurological deficit elicited. Questions. 1) what is the diagnosis? 2) what is the classification of the fracture?

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  1. ospe KWH

  2. Case 1 • M/38 • Right shoulder contusion after S/F • PE: tenderness and swelling over his right upper chest . No skin impingement and no external wound found. No distal neurological deficit elicited

  3. Questions • 1) what is the diagnosis? • 2) what is the classification of the fracture? • 2) what is the management?

  4. Fracture clavicle

  5. Type I • Type I • distal to the coracoclavicular ligaments. • Coracoclavicular ligaments remain intact, • Displacement uncommon. • Treatment = sling. • Conoid ligament • Trapezoid ligament • Coracoid process • Acromion • Clavicle

  6. Type IIA • Type IIA • medial to the coracoclavicular ligaments. • Medial fragment frequently displaces superiorly. • Nonunion is frequent. • Treatment = ORIF. Consider hook-plate fixation (Haider SG, JSES 2006;15:419). Consider non-absorbable suture fixation. (Levy O, JSES 2003;12:24).

  7. Type IIB • Type IIB • Between the coracoclavicular ligaments. • Medial fragment frequently displaces superiorly. • Nonunion is frequent. • Treatment = ORIF. Consider hook-plate fixation (Haider SG, JSES 2006;15:419). Consider non-absorbable suture fixation. (Levy O, JSES 2003;12:24)

  8. Type III • Type III • Intra-articular, frequently without ligament disruption. • Generally little or no displacement. • Frequently missed or misdiagnosed as acromioclavicular joint injuries. • May lead to AC arthritis. • Treatment = sling. Consider distal clavicle excision for patients who are symptomatic at 6-12 months after injury.

  9. Case 2 • F/6 • Left elbow contusion after S/F in 2 months ago • c/o: persistent pain after the injury • PE: tenderness and swelling over her left elbow. ROM: 0-90 degree. No distal neurological deficit elicited. • X rays left elbow was taken

  10. Questions • 1) what is the diagnosis? • 2) what is the associated injury to look for? • 3) what is the management?

  11. Answers • Dislocated radial head • Plastic deformity of ulna shaft • Dx : greenstick Monteggia # with anterior radial head dislocation • Rx : ulnar correctional osteotomy + CR radial head +annular ligament repair

  12. Case 3 • M/70 • Left shoulder contusion after S/F • PE: left shoulder in abducted position • X rays of left shoulder was taken

  13. Questions • 1) what is the diagnosis? • 2) what is the method of reduction?

  14. Inferior shoulder dislocation(luxatio Erecta) • Rare , <1% • Result from forceful hyperabduction of shoulder • Reduction method: • 1) Axial (inline) traction • 2) Two step reduction

  15. The axial traction/countertraction method. Axial traction is applied to the arm with parallel countertraction using a sheet wrapped over the shoulder. Increasing the degree of abduction (if possible) and applying cephalad pressure to the displaced humeral head (star) can aid in reduction.

  16. After reduction of the inferior dislocation, adduct, supinate, and immobilize the arm for postreduction radiography.

  17. Step one, part one. Push anteroinferiorly on the mid humerus with hand A while "pulling" posteriorly on the medial condyle with hand B.

  18. Step one, part two. After conversion of the inferior to an anterior dislocation, adduct the arm and grasp the patient's wrist

  19. Step two. Hand A holds the patient's arm in abduction while hand B externally rotates the arm to reduce the now anteriorly dislocated humeral head.

  20. Case 4 • M/24 • He complained of epigastric and LUQ abdominal pain after having been assaulted by someone on two days ago. • PE: tenderness over his LUQ abdomen. No external wound was found. • BP 148/74 mmHg P93/min SaO2 99%

  21. His BP drop to 60/30 mmHg after admission and return to 130/70 mmHg after 1000 ml gelofusin infusion. • Urgent CT was performed

  22. Plain films

  23. Plain films

  24. Plain films

  25. Contrast film

  26. Contrast films

  27. Contrast films

  28. Contrast films

  29. Contrast films

  30. Delay contrast films

  31. Delay contrast

  32. Delay contrast

  33. Delay contrast

  34. Questions • 1) describe the CT findings • 2) what is the diagnosis? • 3) What is the abnormal CT findings that indicate surgical intervention ? • 4) what is the management?

  35. Answers • Hyperdense peri-splenic hematoma • Scatter intrasplenic hypodense area, suggestive of hematoma and ischemic area • Curvilinear ill-defined hyperdensities are seen within the hypodense region, suggestive of active bleeding • Contrast brush in intrasplenic hypodense area in delay contrast films

  36. Dx : intrabdominal hematoma due to splenic laceration and presence of active bleeding • Rx : spleenectomy

  37. Case 5 • F/25 • She attempted suicide by burning charcoal at home • PE: GCS 14/15, BP 98/73 mmHg, Pulse 83/min, SaO2 99% on 100%O2 • Systems review were unremarkable. No focal neurological sign elicited.

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