Case Presentations TRAUMA

S.P.O.R.C. 2012 Dr. Chantal Janelle

Case 1- S.C.
7 Y.O. healthy boy, C/O L elbow pain. Fell skiing on outstretched L hand earlier on today. Patient transferred from a peripheral hospital where he had a manipulation of L elbow under sedation.

Case 1- S.C.
Current assessement: C/O L elbow pain Exam out of slab: Diffuse moderate swelling L elbow Pain ++ lateral aspect Neurovasc. Intact distally Discussion X-rays (next slide)

Case 1- S.C.

Case 1- S.C
X-Rays L forearm

Management?

Case 1- S.C.
Ct- Scan L Elbow

Management?

Case 1- S.C
Under G.A. : Attempt at closed reduction is unsuccessful Retrograde elastic nailing L radius up to fracture Open reduction of fracture (Kocher approach) Elastic nail advancement into proximal fragment

Case 1- S.C
Intra op X-Rays

Case 1- S.C
Post-op regimen? Potential complications?

Case 2 N.V.
15 Y.O. healthy boy Soccer injury: Patient was about to kick the ball when an opponent facing him kicked his leg. P/E: Swelling +++ and pain L knee Unable to contract quad. or to lift leg from the bed N neuro-vascular exam distally Discussion? X-Rays(next slide)

Case 2 N.V.
X-Rays L knee

Management?

Case 2 N.V.
Patient taken to O.R. O.R.I.F.

Post-op regimen?

Case 2 N.V.
Post-op: Cylinder cast x 6 weeks,toe touch AROM / strenghtening / WBAT at 6 weeks

Case 3 B.L.
14 y.o. fell off a snow skate x 24h Transferred from a regional hospital . C/O pain L ankle, immobilized in a post. slab . P/E: Swelling ++++ L ankle N sensation, moves toes in FL/EXT N cap.refill Compartments are soft Discussion?

Case 3 M.L.-P.
X-Rays L ankle:

Discussion?

Case 3 M.L.-P.
Attempt at closed reduction under ketamine sedation: unsuccessful Management? Above knee posterior slab R.I.C.E. Admission CT-SCAN

Case 3 M.L.-P.
CT-SCAN ( transverse) :

Case 3 M.L.-P.
CT-SCAN (sagittal) :

Case 3 M.L.-P.
CT-SCAN (coronal) :

Case 3 M.L.-P.
Management? Patient D/C home Pt return in clinic 10 days later P/E: Swelling improved, skin wrinkles + NV intact Final Treatment?

Case 3 M.L.-P.
ORIF L ankle: 1- Ant. approach for O.R. of Tillaux and med. mall. fx 2-ORIF of post. fx with use of a pelvic clamp,(post.-lat. approach) 3-internal fixation Tillaux and med.mall. 4- Fibular fx stable ,therefore not fixed

Case 3 M.L.-P.

Case 3 M.L.-P.
10 days post-op: Wounds are clean, staples removed Full below knee cast,NWB with crutches

Case 3 M.L.-P.
6 weeks post-op: Start ROM and PWB

Case 4 - C.S.
9 y.o. female RHD Fell off a trampoline, landed on R elbow C/O pain R elbow P/E: Deformity R elbow 1 cm wound and bruising ant.-med. aspect R elbow Decreased 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?

Case 4 - C.S.
X-Rays R elbow :

Management?

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 :( - )

Case 4 - C.S.
At 4 weeks : Cast and K-W removed start ROM / strengthening At 12 weeks: P/E: thenar atrophy, decreased sensation TF,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

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: 4/5 ROM elbow: 15 FL -130 FL (vs 10 hyperext.-150 FL)

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

Case 5 - P.-S.M.
Labs: Normal X-Rays: Bil. femurs (ref.: next slide) Chest: (-) CT Scan abdomen/pelvis: (-)

Case 5 - P.-S.M.
X-Rays: AP Pelvis, (R) Femur

Case 5 - P.-S.M.
X-Rays: (L) Femur

Case 5 - P.-S.M. Discussion:

Initial management? Treatment options? Final Treatment?

P.-S. M. (2001-01-12)

Initial Treatment:
Bilateral skin traction

X-Rays: (R) Femur

X-Rays: (L) Femur

Discussion: Final treatment?

P.-S. M. (2001-01-12)

Case 5 - P.-S.M.
Treatment:
Patient taken to O.R. closed reduction Elastic nailing

Bilateral femurs

P.-S. M. (2001-01-12)

Post-Op X-Rays:
X-Rays: (R) Femur X-Rays: (L) Femur

P.-S. M. (2001-01-12)

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.
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

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

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.
Patient Admitted under Ortho. Service Labs:
CBC
Hb: 104 PLT: 552 000 WBC: 12,1 Neutro: 0,17 Lympho: 0,74 (95 135) () (6,0 - 17,5)

Calcium: 2,55 (2,25 2,75) Phosphorus: 1,90 (1,40 2,90) Sedimentation: 5 CRP: Negative Coagulation workup: Normal

X-Rays: (L) Lower Extremity

P.T. (2005-12-03)

X-Rays: (L) Tibia

P.T. (2005-12-03)

X-Rays: (L) ankle

P.T. (2005-12-03)

Case 6 P.T.
Differential diagnosis? Further investigation?

P.T. (2005-12-03)

Investigation - 1
Bone Scan & Gallium Scan : Mild uptake (L) Distal Tibial Physis

Bone Scan

Gallium Scan
P.T. (2005-12-03)

Investigation - 2
Skeletal Survey: Negative Head CT Scan: Negative Ophtalmologic consultation: Normal findings Pediatric consultation Social services consultation

P.T. (2005-12-03)

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 (grandfather) required at all times with one or both parents
P.T. (2005-12-03)

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