Fractures of the Upper Limb

November 26, 2015 at 2:05 pm | Posted in Life as a Medical Student, Notes | Leave a comment
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P/s: As usual, I did not owe this note. Credit should be given to Appley and Netter’s Concise Orthopaedic and of course my lecturers 😉

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1. Proximal humerus # in adult (elderly and osteoporotic)

Management depends on parts. (Neer Classification – head, GT, LT, shaft)
🔵 Undisplaced/minimally displaced: sling
🔵 2 fragments: closed reduction & splint.
🔵 3 fragments: operative
🔵 4 fragments: ORIF in young, may consider hemiarthroplasty in elderly.

Complications:
Shoulder stiffness
Brachial plexus injury
AVN (Anatomical neck #)
Nonunion

2. Shaft #
🐛Management:

Usually treated close (CMR + casting) as humerus heal readily. Complications following operative management higher.

ORIF (either plating/nailing) is still indicated in open #, severe comminuted #, polytrauma, unstable #.

🐛Humerus can accept more angulation due to presence of both elbow and shoulder joints.
Can accept up to <3cm shortening <20°AP angulation and <40° lateral angulation.

🐛Complications:
Distal 3rd #, radial nerve palsy, however mostly are neuropraxia. Why? Radial nerve in spiral groove, can become trapped easily. 

3. Distal Humerus #
🐞In adults, mostly intraarticular, either bicondylar or unicondylar.
Extraarticular (supracondylar) but very rare.

🐞Management, as usual:
Undisplaced, treated close.
Displaced, need anatomical reduction, hence ORIF.

🐞Complications:
1. Ulnar nerve palsy. (Ulnar is situated posterior to medial epicondyle).
2. Median nerve palsy. (enters forearm at biceps aponeurosis)
3. Elbow stiffness
4. HO

4. Supracondylar # in children
:idea:Most common, extension type (posterior displacement), Gartland classification.

:idea:X ray: Fat pad sign. Fat pad at coronoid and olecranon fossa is displaced.

:idea:Management:
Gartland 1: casting
Gartland 2 & 3: CMR and k wire.
Children has good remodelling and thick cortex. K wire itself sufficent.

Rarely need ORIF. Still indicated for unreduced #, vascular involvement.

:idea:Complications:
1. Nerves injury
– Radial (between brachialis and BR @ posterior elbow)
– Median (jaggered fragments poke the median nerve/AIN)
– Ulnar
2. Vascular injury – brachial artery (same mechanism as median nerve injury)
3. Malunion – cubitus varus. Usually due to angulation.

5. Elbow dislocation
🌼Simple or Complex (with fractures of the surrounding structures). Posterior dislocation commonest.

🌼Terrible triad: Dislocation with radial head & coronoid #.

🌼Tx.
Simple – simply by closed reduction, then splint (collar and cuff for 1 week, start exercise after that, off by 3rd week)
Complex – settle the # first.

🌼Complications:
1. Nerve injury.
-Ulnar nerve (in cubital tunnel)
-Median nerve in Ligament of Struthers)
Both can become compressed
2. Vascular injury – Brachial artery
3. Elbow stiffness and instability.

➡ Recurrent dislocation very rare

6. Fractures of the Radius and Ulnar
Manage like an intraarticular #, needs anatomical reduction. Why? Presence of supinator and pronator muscle. Not easy to maintain reduction.

👉Both bone #
Paeds, closed reduction and casting. Remodelling is very good.
Adult, ORIF (plating)

👉Single bone #
Monteggia: Prox ulnar # with PRUJ disruption (radial head dislocation due to shortening force @ ulnar)
Mx: ORIF. Dislocation will reduce when # has been managed

Galleazi: Distal 1/3 radial # with DRUJ disruption
Mx: ORIF, DRUJ closed reduction.

7. Distal End Radius #
MOI: Axial force, FOOSH
Common, esp in osteoporotic pt.

✴ Colles #, dinner fork deformity ( dorsal displacement)
✴ Smith #, reverse Colles

Classification:
Frykman for Colles (joint involvement)
Even number – ulnar styloid #
1&2 Extraarticular
3&4 RC joint
5&6 RU joint
7&8 Both RC and RU involved

Management:
Undisplaced: cast
Displaced:
Extraarticular (close reduction, check X-Ray, Rule of 11). If unstable, ORIF
Intraarticular, need ORIF.

Old and osteoporotic ➡ allow more conservative mx as use the joint less.

Complications:
-malunion
-stiffness
-median nerve injury (carpal tunnel)
-TFCC injury (important for stability)

😇TFCC
Triangular fibrocartilage complex
-between distal ulnar and ulnar prox carpal row (triquetrium)
-Ligaments – central disc, dorsal radioulnar, palmar radioulnar.

8. Scaphoid #
Tenderness @ snuffbox region.

🔺Mx:
70% of scaphoid covered by articular cartilage, hence mx line intraarticular #.
Displace # need anatomical reduction (headless screw compression)

🔺Complications:
– AVN esp if injury at proximal part.
Blood vessel enters in a nonarticular ridge on the dorsal surface. Prox part supplied by retrograde blood flow.
– Non-union

Terlebih Air?

June 14, 2015 at 10:45 am | Posted in Life as a Medical Student, Renungan | Leave a comment
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فَبِأَيِّ آلَاءِ رَبِّكُمَا تُكَذِّبَانِ

Maka yang mana satu di antara nikmat-nikmat Tuhan kamu, yang kamu hendak dustakan?

🌹🌹🌹🌹🌹🌹🌹🌹🌹🌹

“Pakcik, kenapa pakcik datang hospital ni?”

“Sesak nafas. Air penuh dalam paru-paru doktor kat kecemasan kata…” jawab pakcik tersebut. Pakcik yang berada dalam lingkungan 60an tersebut tetap ceria di sebalik oxygen mask yang dipakainya.

“Pakcik kamu ni haa. Doktor tak bagi minum air banyak. Maximum satu botol kecik ni je (500 ml) sehari, tapi dia tak dengar. Nak minum banyak jugak. Puas dah kami anak-anak cakap, dia buat tak endah je.” Panjang leteran si anak yang menjaga ayahnya itu.

“Lah, tengok dalam TV tu iklan kesihatan. Kata musim panas kene minum banyak air… pakcik minum laa. Mana laa tahan musim panas ni nak minum air sikit nak oi.” Jawab pakcik tersebut sambil ketawa.

“Laa.. iklan tu bukan untuk orang-orang special yang Allah uji macam pakcik…”

Berderai tawa pakcik tersebut dengan anaknya.

“Pakcik, kalau rasa panas, kemam ais dalam mulut. InsyaAllah hilang sikit rasa haus tu…”

Pakcik tersebut mengangguk-angguk.

Memang pakcik ni jenis ceria, getus hatiku. Walaupun di katil acute, nafas masih semput, high flow mask masih di muka, tetap boleh bergelak ketawa. Pakcik ini dikejarkan ke jabatan kecemasan disebabkan terlebih air dalam badan “fluid overload” kerana melanggar pantang air yang diberikan oleh doktor, “restriction of fluid” (ROF). Beliau mengidap masalah kerosakan buah pinggang, komplikasi daripada penyakit kencing manis beliau yang tidak terkawal.

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Restriction of fluid (ROF).

Ini bermakna, dalam tempoh 24 jam, pesakit hanya boleh mengambil air mengikut sukatan yang telah diberi oleh doktor. Ada yang 500 ml sehari, ada juga yang 800 ml sehari. Kalau terlebih air, pesakit boleh mendapat symptom-symptom “fluid overload” seperti susah bernafas dan kaki bengkak.

Kebiasaannya, ROF ini untuk pesakit-pesakit lemah jantung dan juga pasakit yang mengalami kerosakan buah pinggang yang kronik (tahap 4, tahap 5, atau yang sedang melalui dialisis).

Badan manusia yang normal, sebanyak manapun air yang kita ambil, ia akan mampu diproses oleh buah pinggang dan jantung dengan baik. Lagi banyak air yang kita ambil, lagi banyak air kencing akan dihasilkan.

Rasa haus, secara spontan kita meneguk air.

Nikmat untuk minum air adalah nikmat yang jarang kita syukuri.

Kemampuan badan kita untuk memproses air tersebut juga merupakan nikmat yang selalu kita ambil ringan.

Alhamdulillah atas nikmat kesihatan yang Allah berikan pada kita. Sejauh mana telah benar-benar kita syukuri?

Semoga Ramadhan yang bakal mendatang ini, menyedarkan kita akan erti syukur.

“Maka yang mana satu di antara nikmat-nikmat Tuhan kamu, yang kamu hendak dustakan?”

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