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?
• 2) what is the management?
Fracture clavicle
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
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).
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)
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.
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
Questions
• 1) what is the diagnosis?
• 2) what is the associated injury to look for?
• 3) what is the management?
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
Case 3
•
•
•
•
M/70
Left shoulder contusion after S/F
PE: left shoulder in abducted position
X rays of left shoulder was taken
Questions
• 1) what is the diagnosis?
• 2) what is the method of reduction?
Inferior shoulder dislocation
(luxatio Erecta)
• Rare , <1%
• Result from forceful hyperabduction of
shoulder
• Reduction method:
• 1) Axial (inline) traction
• 2) Two step reduction
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.
After reduction of the inferior dislocation, adduct, supinate, and
immobilize the arm for postreduction radiography.
Step one, part one. Push anteroinferiorly on the mid humerus with
hand A while "pulling" posteriorly on the medial condyle with hand
B.
Step one, part two. After conversion of the inferior to an anterior
dislocation, adduct the arm and grasp the patient's wrist
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.
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%
• His BP drop to 60/30 mmHg after
admission and return to 130/70 mmHg
after 1000 ml gelofusin infusion.
• Urgent CT was performed
Plain films
Plain films
Plain films
Contrast film
Contrast films
Contrast films
Contrast films
Contrast films
Delay contrast films
Delay contrast
Delay contrast
Delay contrast
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?
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
• Dx : intrabdominal hematoma due to
splenic laceration and presence of active
bleeding
• Rx : spleenectomy
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.
Question
• 1) describe the CT findings
• 2) what is the diagnosis?
• 3) what is the management?
Answers
• Symmetrical hypodensity noted at bilateral
basal ganglia
• Compatible with CO poisoning
• Rx : stabilize ABC
• Administer 100%O2 via tight fitting face
mask
• Intubate and provide IPPV on 100%O2 if
unconscious
• Record ECG, check ABG, COHB level
• Consider hyperbaric oxygen therapy if
• COHB >25%, pregnant patients with
COHB >10%, myocardial ischemia,
worsening symptoms despite oxygen
therapy, all patients with syncope,
neurological or cardiac abnormalities with
elevated COHB
Case 6
• F/25, Phx depression
• Attempted suicide by drug overdose
• PE: unconscious, GCS 4/15, BP 100/60
mmHg Pulse 70/min
• She was intubated in AED.
Questions
• 1) describe the ECG finding
• 2) what is the diagnosis?
• 3) what is the mangement?
Answers
• Widening QRS complex, terminal 40ms
rightward axis shift, non-sustained VT
• Dx : TCA overdose
• RX : stabilize ABC
• Sodium bicarbonate boluses and infusion
to narrow QRS to <100ms and keep PH
7.45 to 7.55
Case 7
• M/37
• Family history of premature death of
unknown cause
• Complained of palpitation and atypical
chest discomfort for few episodes.
• PE: BP 140/80 mmHg P 95/min
• Systems review were unremarkable.
Questions
• 1) describe the ECG findings
• 2) what is the diagnosis?
• 3) what is the management?
Answers
• Sinus rhythm with ST segment elevations
in V1-V3
• Dx : brugada syndrome
• Associated with syncope and sudden
death
• PE and echocardiogram to exclude other
cardiac causes
• Electrophysiologic study to determine the
inducibility of arrhythmias for risk
stratification
• Serum K & Ca levels : ECG patterns in
hyperkalemia and hypercalcemia similar to
that of brugada syndrome
• Cardiac enzyme and troponin in patients
with symptoms compatible with ACS
• No pharmacological therapy has proven to
reduce the occurrence of ventricular
arrhythmias or sudden death
• The only proven effective treatment in
prevent sudden death and treating
Ventricular arrhythmias is implantation of
an automatic implantable cardiac
defibrillator (ICD).