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Case Presentations
TRAUMA
S.P.O.R.C. 2012
Dr. Chantal Janelle
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Case 1- S.C.
7 Y.O. healthy boy, C/O L elbow pain.
Fell skiing on outstretched L hand earlieron today.
Patient transferred from a peripheralhospital where he had a manipulation of Lelbow under sedation.
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Case 1- S.C.
Current assessement:
C/O L elbow pain
Exam out of slab: Diffuse moderate swelling L
elbowPain ++ lateral aspect
Neurovasc. Intact distally
Discussion
X-rays (next slide)
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Case 1- S.C.
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Case 1- S.C
X-Rays L forearm
Management?
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Case 1- S.C.
Ct- Scan L Elbow
Management?
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Case 1- S.C
Under G.A. : Attempt at closed reductionis unsuccessful
Retrograde elastic nailing L radius up tofracture
Open reduction of fracture (Kocherapproach)
Elastic nail advancement into proximalfragment
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Case 1- S.C
Intra op X-Rays
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Case 1- S.C
Post-op regimen?
Potential complications?
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Case 2 N.V.
15 Y.O. healthy boy
Soccer injury: Patient was about to kick the ballwhen an opponent facing him kicked his leg.
P/E: Swelling +++ and pain L kneeUnable to contract quad. or to lift leg from thebed
N neuro-vascular exam distally
Discussion?
X-Rays(next slide)
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Case 2 N.V.
X-Rays L knee
Management?
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Case 2 N.V.
Patient taken to O.R.O.R.I.F.
Post-op regimen?
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Case 2 N.V.
Post-op: Cylinder cast x 6 weeks,toe touchAROM / strenghtening / WBAT at 6weeks
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Case 3 B.L.
14 y.o. fell off a snow skate x 24hTransferred from a regional hospital .C/O pain L ankle, immobilized in a post. slab .
P/E:Swelling ++++ L ankleN sensation, moves toes in FL/EXTN cap.refill
Compartments are soft
Discussion?
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Case 3 M.L.-P.
X-Rays L ankle:
Discussion?
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Case 3 M.L.-P.
Attempt at closed reduction underketamine sedation: unsuccessful
Management?Above knee posterior slab
R.I.C.E.
AdmissionCT-SCAN
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Case 3 M.L.-P.CT-SCAN ( transverse) :
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Case 3 M.L.-P.
CT-SCAN (sagittal) :
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Case 3 M.L.-P.CT-SCAN (coronal) :
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Case 3 M.L.-P.
Management?
Patient D/C homePt return in clinic 10 days later
P/E: Swelling improved, skin wrinkles +
NV intactFinal Treatment?
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Case 3 M.L.-P.
ORIF L ankle:
1- Ant. approach for O.R. of Tillaux andmed. mall. fx
2-ORIF of post. fx with use of a pelvicclamp,(post.-lat. approach)
3-internal fixation Tillaux and med.mall.
4- Fibular fx stable ,therefore not fixed
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Case 3 M.L.-P.
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Case 3 M.L.-P.
10 days post-op:Wounds are clean, staples removed
Full below knee cast,NWB with crutches
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Case 3 M.L.-P.
6 weeks post-op:
Start ROM and PWB
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Case 4 - C.S.
9 y.o. female RHD
Fell off a trampoline, landed on R elbowC/O pain R elbow
P/E: Deformity R elbow
1 cm wound and bruising ant.-med. aspect R elbowDecreased sensation over volar aspect of TF,IF,MF.
Weakness of FPL and FDP IF and TF opposition.
Weak, intermittent radial pulse.
Cap. Refill : 2-3 sec.
Diagnosis?
Discussion?
C 4 C S
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Case 4 - C.S.X-Rays R elbow :
Management?
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Case 4 - C.S.
I.V. antibiotics, ( tetanus vacc. up to date)Wound debridement
O.R.I.F. with K-Wires, post. slab
Vascular exploration :( - )
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Case 4 - C.S.
At 4 weeks : Cast and K-W removed
start ROM / strengthening
At 12 weeks:
P/E: thenar atrophy, decreased sensationTF,IF,MF(improved from before)
FPL and FDP IF : 3+/ 5
Finger ABD and EXT: 5 / 5
ROM elbow : 30-110 P/S: 80/90 Wrist : N
X-Rays: Fx healed
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Case 4 - C.S.At 6 months:
Sensation assessed by monofilaments (O.T.):Protective sensation over TF,IF,MF
FPL and FDP IF: 4+/5
Thumb abduction: 4/5ROM elbow: 15 FL -130 FL (vs 10 hyperext.-150 FL)
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Case 5 - P.-S.M.
5 y.o. boy
HX :
MVA, low velocity impact No loss of consciousness Pain bilateral lower extremities
Diffuse abdominal pain
P/E : Stable V.S. Normal level of consciousness
Abdomen: Tenderness (L) lower quadrant Swelling / deformity bil. thighs, no wound (N) NV exam bilaterally
Discussion
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Case 5 - P.-S.M.
Labs:
Normal
X-Rays:
Bil. femurs (ref.: next slide) Chest: (-)
CT Scan abdomen/pelvis: (-)
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Case 5 - P.-S.M.
X-Rays: AP Pelvis, (R) Femur
C 5 P S M
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Case 5 - P.-S.M.
X-Rays: (L) Femur
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Case 5 - P.-S.M.
Discussion:
Initial management?
Treatment options? Final Treatment?
P.-S. M. (2001-01-12)
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Initial Treatment:
Bilateral skin traction
X-Rays: (R) Femur X-Rays: (L) Femur
Discussion: Final treatment?
P.-S. M. (2001-01-12)
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Case 5 - P.-S.M.
Treatment:
Patient taken to O.R.
closed reduction Elastic nailing
Bilateral femurs
P.-S. M. (2001-01-12)
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Post-Op X-Rays:
X-Rays: (L) FemurX-Rays: (R) Femur
P.-S. M. (2001-01-12)
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Case 6 P.T.
7 weeks old boy, healthy
Brought to E.R. by parents for ROM (L) L.E.
Discussion
Case 6 P T
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Case 6 P.T.
PMH:
N (full-term) pregnancy Born/vaginal delivery Vertex presentation B.W.: 2800g APGAR: 9-9-10
Family History: - Negative
Meds: none
Allergies: none
Discussion
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Case 6 P.T.
HX :
Parents have noticed ROM (L) L.E. x 5 days No fever
No Hx of trauma N Milk intake System review: (-)
Discussion
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Case 6 P.T.
P/E :
N V.S.T : 37.4 C (L) L.E.: ? mild swelling (L) leg, no redness
AROM, N PROM
Otherwise normal MSK exam
Investigation?
Plan?
Case 6 P T
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Case 6 P.T.Patient Admitted under Ortho. Service
Labs: CBC
Hb: 104 (95 135)PLT: 552 000 ()WBC: 12,1 (6,0 - 17,5)
Neutro: 0,17
Lympho: 0,74
Calcium: 2,55 (2,25 2,75)
Phosphorus: 1,90 (1,40 2,90) Sedimentation: 5 CRP: Negative Coagulation workup: Normal
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X-Rays: (L) Lower Extremity
P.T. (2005-12-03)
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X-Rays: (L) Tibia
P.T. (2005-12-03)
X Rays: (L) ankle
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X-Rays: (L) ankle
P.T. (2005-12-03)
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Case 6 P.T.
Differential diagnosis?
Further investigation?
P.T. (2005-12-03)
I ti ti 1
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Gallium ScanBone Scan
Bone Scan & Gall ium Scan : Mild uptake (L) Distal Tibial Physis
Investigation - 1
P.T. (2005-12-03)
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Investigation - 2
Skeletal Survey: Negative
Head CT Scan: Negative
Ophtalmologic consultation: Normalfindings
Pediatric consultation
Social services consultation
P.T. (2005-12-03)
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Case 6 P.T.
Final Diagnosis:- Physeal fracture (L) distal tibia
Final plan:- D.Y.P. involved
Child discharged home
Presence of a family member (grand-father) required at all times with one orboth parents
P.T. (2005-12-03)
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THANK YOU !