OPEN FRACTURE 1/3 DISTAL RIGHT RADIUS

OPEN FRACTURE 1/3 DISTAL RIGHT ULNA

PRESENTED BY:Astari Pratiwi Nuhrintama

C 111 09 270ADVISORS:

dr. Prori Fatwa Noor I dr. Satria Prawira Putra

SUPERVISOR:dr. Jainal Arifin, M.Kes, SpOT

ORTHOPAEDIC AND TRAUMATOLOGY DEPARTMENTMEDICAL FACULTY

HASANUDDIN UNIVERSITY2014

PATIENT’S IDENTITY

¤ Name : Ms. D¤ Gender : Female¤ Age : 22 years old¤ Medical Record: 666983¤ Admission : June 8th 2014

CHIEF COMPLAINT: wound at right forearm• Suffered since ±5 hours before admitted to

Wahidin General Hospital due to traffic accident

• The patient was a passenger of a motorcycle and then fell by themselves with the right forearm first.

• History of unconscious (-), vomit (-), nausea(-)

• Prior treatment at Maros Hospital

HISTORY TAKING

PHYSICAL EXAMINATION

Primary Survey

Secondary Survey

A PatentB RR: 20x/minutes, symmetric, spontaneous, thoracoabdominal typeC BP: 120/70 mmHg, HR: 90x/minutes, regular, strongD GCS 15 (E4M6V5), light reflex +/+, pupil isochors Ø 2,5 cm/2,5 cm

E T: 37°C (axillary)

Primary Survey

Secondary Survey Right Forearm Region

• Lacerated wound at posteromedial aspect, size 5x0,5cm

• Deformity (+), Swelling (+), Hematoma (+)LOOK• Tenderness (+)FEEL

• Sensibility of radial, ulnar, & medianus distribution are good

• Radial artery & ulnar artery are palpable• CRT < 2 seconds

NVD• Active and passive movement of wrist and elbow

joints can’t be evaluated due to painMOVE

CLINICAL PHOTOS

ADDITIONAL EXAMINATION

Laboratory

Radiology

June 8th 2014WBC 12500 /mm3 CT 8”

RBC3,77x

10⁶/mm3BT 3”

HB 11,8 g/dL HbsAg Non ReactiveHCT 35 %PLT 226000/mm3

Laboratory Finding

X Ray Right Forearm AP/Lat

• Woman, 22 year old came to the hospital with fracture 1/3 distal right radius and fracture 1/3 distal right ulna that caused by traffic accident.

• At the right forearm examination, there are lacerated wound posteromedial aspect, size 5cm x 0,5cm, deformity, swelling, hematoma, and pain.

RESUME

Open fracture 1/3 distal right radius

DIAGNOSIS

Open fracture 1/3 distal right ulna

• IVFD• Analgesic• Antibiotic• Tetanus Prophylaxis• Immobilization• Debridement• Plan for ORIF

MANAGEMENTS

DISCUSSION

FractureRadius and Ulna Shaft

FRACTURE RADIUS AND ULNA SHAFT

• Forearm fractures are more common in men than women; secondary to the higher incidence in men of motor vehicle accidents, contact athletic participation, altercations, and falls from a height.

• The ratio of open fractures to closed fractures is higher for the forearm than for any other bone except the tibia

Epidemiology

Handbook of Fracture, Part III: Upper Extremity Fractures and Dislocations, Chapter 21: Radius and Ulna Shaft

Anatomy : Osteology

Netter’s Concise Orthopaedic Anatomy. Chapter 5: Forearm, Osteology.

FRACTURE RADIUS AND ULNA SHAFT

Anatomy: Muscles, Compartments

Review of Orthopaedics. Chapter 2 Anatomy, Section 2: Upper Extremity

Anterior (Superficial & Deep)

Posterior (Superficial & Deep)

PTFCRPL

FCU

FDS

PQ

FDP

FPL

ANC

ECU

EDMEDC

ECRB

ECRL

BR

APL

EPB

SUP

EPLEIP

• These fractures are most commonly associated with:• high-energy accidents, • although they are also commonly caused by direct trauma (while protecting one's head),

• gunshot wounds, and• falls either from a height or • during an athletic competition.

• Pathologic fractures in this area are uncommon.

Mechanism of Injury

Handbook of Fracture, Part III: Upper Extremity Fractures and Dislocations, Chapter 21: Radius and Ulna Shaft

FRACTURE RADIUS AND ULNA SHAFT

• Pain, swelling, deformity, lost of forearm function• Tenderness at the fracture site• Crepitus (painful and may cause additional

damage)• Motor and sensory function of the radial, median,

and ulnar nerves • Radial and ulnar pulse and distal capillary refill• The forearm is at high risk for developing

compartment syndrome.

Signs and Symptoms

Fracture Management for Primary Care. Chapter 6: Radius and Ulna Fractures

FRACTURE RADIUS AND ULNA SHAFT

Radiographic Evaluation

Apleys System of Orthopaedics and Fractures. Part 3: Fractures and Joint Injuries. Chapter 23: Principle of Fracture

• AP/Lateral viewsTwo Views• Wrist and elbow joints for see

angulation of the bone or dislocation

Two Joints• The abnormality can be appreciate

only by comparison with the normal side

Two Limbs

• To eliminate associated fractureTwo Injuries

• To confirm the diagnoseTwo Occasion

“Rule of Two”

FRACTURE RADIUS AND ULNA SHAFT

Gustilo and Anderson Classification of Open

Fractures

Handbook of Fracture,. Part I: General Considerations. Chapter 3: Open Fracture

Type Wound

Level of Contaminati

onSoft Tissue Injury Bone Injury

I < 1 cm long Clean Minimal Simple, minimal communition

II > 1 cm long Moderate Moderate, some muscle damage

Moderate comminution

IIIA Ussually

> 10 cm longHigh Severe with crushing Ussually communited;

soft tissue coverage of bone possible

B Ussually > 10 cm long

High Very severe loss of coverage; usually

requires soft tissue reconstructive surgery

Bone coverage poor; variable, may be

moderate to severe communition

C Ussually > 10 cm long

High Very severe loss of coverage plus vascular injury requiring repair; may require soft tissue reconstructive surgery

Bone coverage poor; variable, may be

moderate to severe comminution

Mueller AO Classification (Forearm Region)

Handbook of Fracture,. Part I: General Considerations. Chapter 3: Open Fracture

4R

Treatment

Recognation• Fracture site, Types of fracture

Reduction• For adequate apposition and normal

alignment of boneRetention• Immobilize promote soft tissue healing

Rehabilitation• As early possible by ctive and passive

exercise (restore function)

FRACTURE RADIUS AND ULNA SHAFT

Apley’s System of Orthopaedics and Fractures

Treatment

Apley’s System of Orthopaedics and Fractures

PRINCIPLES

• Make sure for the life threatening condition is clear

• Give the analgesic if needed• Early administration antibiotic and tetanus

prophylaxis• Stabilization of the fracture• Prompt wound debridement• Plan for open reduction and internal fixation

FRACTURE RADIUS AND ULNA SHAFT

Treatment

AO Principles of Fracture Management. Chapter 4: Spesific Fractures, 4.3: Forearm and Hand

Treatment of forearm shaft

fractures is mainly surgicalGOALS OF TREATMENT

• Restoration of length, axial alignment, and rotation so as to guarantee full pronation and supination.

• Fixation sufficient to allow free postoperative movement of adjacent joints.

FRACTURE RADIUS AND ULNA SHAFT

Complication

EARLY

Compartment Syndrome

Neurovascular Injury

Fat Embolism

LATE

Non UnionDelayed Union

MalunionJoint Stiffness

Infection

Handbook of Fracture, Part III: Upper Extremity Fractures and Dislocations, Chapter 21: Radius and Ulna Shaft

FRACTURE RADIUS AND ULNA SHAFT

THANK YOU