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Nearly amputation+nail bed inj

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Nichakorn

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Nearly amputation+nail bed inj

  1. 1. Nichakorn Boonyabaramee
  2. 2. Chief complain ซ้อนมอเตอร์ไซค์ล้ม นิ้วกลางซ้ายโดนแฮนด์ รถทับ 4 ชั่วโมงก่อนมาโรงพยาบาล
  3. 3.  A : patent airway ,no tender at C-spine  B : no dyspnea ,RR20  C : pulse full , BP 131/89  D : E4V5M6 ,pupil 3mm RTLBE  E : Avulsion wound 1 cm at distal phalanx of middle finger, exposed bone
  4. 4. A : no drug allergy M : no current medication P : no underlying disease L : last meal 5 hr PTA E : ซ้อนมอเตอร์ไซค์ ล้มแฮนด์รถทับนิ้วกลางซ้าย มีแผลฉีก ขาดที่ปลายนิ้ว เห็นกระดูก เจ็บบริเวณแผล กระดิกนิ้วไม่ได้ ไม่ มีบาดแผลบริเวณอื่น ศีรษะไม่กระแทกพื้น ไม่สลบ
  5. 5. Avulsion wound 1 cm at distal pharange of left middle finger exposed bone , nearly amputation with active bleeding No capillary refill
  6. 6. Open fracture distal phalange of left middle finger with nearly amputation
  7. 7.  At ER Wound dressing  Operation Excisional debridement with repair nail bed  ก่อนเย็บ No capillary refill หลังเย็บ capillary refill 5 sec
  8. 8. http://www.orthobullets.com/trauma/1003/gustilo- classification
  9. 9.  Initial Management - NPO - Tetanus toxoid 0.5ml IM - Cefazolin 1g IV stat - 5% DN/2 1000 ml IV 80 ml/hr - irrigation wound - compression wound for stop bleeding https://usmlejournal.wordpress.com/2009/11/07/tetanus- prophylaxis/
  10. 10. Fracture of Phalange แบ่งออกเป็น ◦Fracture of distal phalanx associated injury : nail bed injury ◦Fracture of middle and proximal phalanx
  11. 11.  Fracture of distal phalanx  Tuft  Simple or Comminuted  Shaft  Transverse or Longitudinal  Intra-articular  Dorsal or Volar http://cursoenarm.net/UPTODATE/contents/mobipreview.htm?2
  12. 12.  Fracture of distal phalanx  Non operative treatment >> Close reduction & splinting  non displace  No nail bed injury  Operative treatment >> ORIF +/- nail bed repair  Nail bed injury  Unstable intra-articular fracture
  13. 13.  Fracture of distal phalange ในรายนี้มี nail bed injury ร่วมกับ fracture ที่ shaft of distal phalanx เป็น indication ในการรักษาแบบ Operative treatment (ORIF) ใน fracture รูปแบบอื่นที่ stable และไม่มี nail bed injury นั้นสามารถรักษาแบบ non-operative ได้โดยการทา close reduction with aluminum splinting 3 สัปดาห์ ตามด้วย early aggressive motion
  14. 14.  Loss of motion ◦ most common ◦ Associated. with intra-articular fracture  Malunion ◦ Malrotation , angulation, shortening ◦ when patient has functional impairment >> surgery  Nonunion ◦ uncommon ◦ Associated with bone loss or neurovascular compromise
  15. 15.  Treatment ◦ drainage of hematoma by perforation  indications  less than 50% of nail involved  techniques  puncture nail using sterile needle  electrocautery to perforate nail ◦ nail removal, D&I, nail bed repair  indications  > 50 % nail involved  technique  nail bed repair
  16. 16.  Laceration of the nail and underlying nail bed ◦usually present with the nail intact and a subungual hematoma greater than 50% of nail surface area  Treatment ◦nail removal with D&I, nail bed repair
  17. 17.  Associated conditions  distal phalanx fracture  if present reduction is advocated  Treatment ◦ nail removal, nail bed repair, +/- fx fixation  indications  avulsion injury with minimal or no loss of nail matrix, with or without fracture ◦ nail removal, nail bed repair, split thickness graft vs. nail matrix transfer, +/- fx fixation  indications  avulsion or crush injury with significant loss of nail matrix  fracture fixation depends on fracture type
  18. 18.  ออร์โธปิดิกส์ ฉบับเรียบเรียงใหม่ครั้งที่ 3 คณะแพทยศาสตร์ รพ. รามาธิบดี  http://cursoenarm.net/UPTODATE/contents/mobipreview.htm?27/55/2 8533  https://usmlejournal.wordpress.com/2009/11/07/tetanus-prophylaxis/  http://www.orthobullets.com/trauma/1003/gustilo-classification  http://www.orthobullets.com/hand/6114/phalanx-fractures  http://www.orthobullets.com/hand/6109/nail-bed-injury
  • nattakul

    Jul. 28, 2017

Nichakorn

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