Image of the Day 32: Left Posterior Medial Elbow Dislocation

17 years old boy presented to Emergency Department due to severe pain of left elbow region and unable to bend the elbow joint after fall while skate boarding.

Examination of the left arm reveal a deformed elbow joint and palpation reveal prominent olecranon at the medial side of the elbow joint. It is warm, tender and reduce in range of movement. examination of distal artery and nerves are normal.

deformed left elbow

Plain radiograph of the Elbow joint AP and lateral shows posterior and medial elbow dislocation with no fracture line seen.

AP view

Lateral view

Elbow dislocation was reduced under procedural sedation and analgesia and post reduction plain radio graph shows satisfactory reduction

Reducing elbow joint dislocation. Image taken from Primary surgery volume 2 at this link [here]

AP View

Lateral view

Back slab was applied in flexion position and patient was discharged with follow up under orthopedic clinic.

See more on elbow dislocation:

Image of the Day 31: Right Posterior Elbow Dislocation [link]

Image of the Day 31: Right Posterior Elbow Dislocation

This unfortunate 56 years old lady presented to casualty after alleged fall to the ground from a low speed moving 4X4 car. Exact mechanism of injury is unknown.

On examination, patient is conscious and alert with full GCS. Vitals sign are stable and pain score is 5/10. Right elbow is deformed, held on extended position and with small laceration wound at the antecubital fossa. Bone otherwise not exposed. Upon palpation, it is tender, warm and in fix extension position. Examination of the peripheral pulses and nerves function are normal.

Radiological image of the right elbow shows posterior dislocation of the elbow joint. No associated fracture seen on the x ray.

Close manual reduction of the dislocated elbow joint then performed under procedural sedation and analgesia using 5 mg of IV midazolam and 75 microgram of IV Fentanyl. Back slab POP is then applied with elbow in 90 degrees of flexion position. No vascular or nerve injury involvement after the procedure.

Patient is discharged with analgesia, antibiotic and follows up as outpatient in orthopedic clinic.

Discussion

Elbow dislocation is the second most common major joint dislocation in adult after the shoulder joint and 90% of it is attributed to Posterior dislocation.

It normally results from a fall onto an extended abducted arm and usually not associated with neurovascular injury.

Usually the elbow would be in flexion position with exaggerated olecranon prominence

Dislocated elbow joint with association of fracture ideally treated with open reduction and internal fixation while those without the fracture can be reduce manually with sedation and analgesia. Post reduction film must be taken and evaluate for any bone fracture after the close reduction.

Wrist Distractor for Barton’s Fracture

Previously i was posting a case of Barton fracture or simply means fracture of distal end of radius extending to the intra articular surface. Basically, if CMR fails, the alternative is by doing a open reduction and internal fixator. 

Well, here is another alternative of treatment that we did here. Using a close reduction under portable x ray machine and fix it with wrist distractor. Alignment is satisfactory and with good result also. 

Radius fracture: [Link]

Answer to Radius fracture notes [Link]

Bedsores

Stage II-III Bedsores. Surrounding the ulcer is an area of hyperemia which manifested as red skin and also necrotic skin. The necrotic skin must be removed and preventive measure should be continued to avoid larger area of bedsores.

1. Basically a gangrene caused by local pressure. Also known as pressure sore or decubitus ulcer

2. Predisposing factor includes PRESSURE, INJURY, ANAEMIA, MALNUTRITION and MOISTURE.

3. Staging of bedsores

Stage I (Impending ulceration)

- Blanchable erythema due to reactive hyperemia

- Resolve within 24 hours of pressure relieves

Stage II (Partial thickness skin loss)

- Involving epidermis or dermis and represented by abrasion, blister or ulcer

Stage III (Full thickness loss)

- May extend to the subcutaneous tissue but not through underlying fascia

Stage IV (Extension into muscle, bone, tendon or joint capsule

4. Prevention includes

- Foam block

- 2 Hourly turning position

- Ripple mattress bed (air bed)

- Good nursing care to avoid contamination from urine, sweat and faeces. (adhesive film)

- Lotion.

- Early ambulation.

5. Treatment

- PREVENTION is a MUST as treatment is very difficult. once a bedsores occur, it will progress and healing process will take a long time. It is a well known fact that managing bedsores are very COASTLY. Besides, bedsore also increase morbidity and mortality rate among hospitalized patient.

- Treatment based on stage

a) Stage I

            Preventive measures

b) Stage II

            Preventive measures + dressing via simple solution (Normal saline or diluted chlorhexidine)

c) Stage III and above

            Preventive measures PLUS

            Dirty wound: Hydrogen Peroxide + Poviderm + Chlorhexidine

Moderately dirty: Vacuum assisted dressing, specialized wound solution with capacity of promoting granulation

            Clean wound: Normal saline

  

-Based on assesment of the wound,

- Vacuum dressing

- Wound debridement

- Skin flap.

- Correction of underlying anemia, hypoalbuminaemia or any malnutrition.

Stage IV bedsores that involves penetration up to sacral bone.

Large area of bedsore. From inspection, it appears as grade II bedsore. However, careful examination should be conducted as superimposed infection will give rise to a deep pocket underlying the skin. this pocket are need to be thoroughly debride so that the wound management would be effective

A successful wound management will promote formation of granulation tissue. however, such a large defect require skin flap and active preventive measures and continuous nursing care to avoid it from being infected.

Spot Diagnosis: Laceration Wound of Dorsum of Hand

40 years old gentleman alleged cut his left hand with parang while doing some farm work.  This picture of hand is taken while asking the patient to extend his fingers

1) Describe your findings

2) What is your spot diagnosis

3) Management for this patient

The anatomy of the Extensor Tendon of the hand

Answer

1) Findings

- oblique laceration wound at the dorsum of hand extending from base of  ring finger to opposite of index finger

- index and middle finger in flexion position / inability to extend the index and middle finger

2) Deep laceration wound with cut of extensor digitorum of left index and middle finger

3) Management

- Wound irrigation

- Pain management (IV Tramadol/ NSAIDs-Paracetamol)

- IV Antibiotic covering gram positive, negative and anaerobs

- Anti tetanous Toxoid injection.
- Hand X Ray -Oblique and AP to exclude any bony involvement
- Full blood count for Hb level. Patient may need blood transfusion if anemia secondary to blood loss. TWBC count may be a helpful marker for infection. Coagulation profile may be helpful if suspected any clotting disorder.

- Wound exploration, debridement and tendon repair

- Thermosplint with hand in extension position for three weeks followed with hand exercise (Flexion-extension of fingers)

Treatment Option for Paediatric Femoral Shaft Fracture

Complete Spiral fracture with Displacement and shortening of Left femur in 6 years old child.

While plating or Intramedullary nail being a famous and traditional treatment for femoral shaft fracture in adult, it remain controversial for the pediatric population.

For ages, conservative treatment with Pavlik harness and early or delayed cast have being implied. Study has shown that it is effective even in a severely displaced fracture or shortening up to 2.5 cm. However, it cause prolong immobilization  leading to loss of school days and need of good nursing care.

Some literature may put a range of age of which treatment is the best but it remain subjective and depends on orthopaedist choice and agreement with the parent. Generally, conservative treatment is best reserved in children less than 5 years old and modality depends for children age from 6 to 13 years old. For the past few decades, the surgical management evolving very fast starting from the use of external fixator till the use of elastic platinum intramedullary nail.

After 2 weeks of skin traction, the shortening become lesser but still no callus formation seen

Various of method has being described and each of the treatment modalities has their own complication that should be discussed with parents.

Exernal fixator may cause pin tract inflammation and sepsis, malunion and refracture. But it may provide excellent result if the child being operated early within 24 hours of events even without prior traction. Usage of traction table prevent the malrotation and support the under leg and reduce the fracture before insertion of first pin.

Intramedullary nail fixation may give rise to avascular necrosis of the head of femur, coxa valga and physis disturbance

Plate and screws is a good choice to prevent rotational deformity and stabilize the fracture but it will leave a long scar, increased infection rate and require revision surgery later.

The problem with conservative treatment is the long duration of hospital stay and this will not only reduce the schooling time but also affect the working parent who needs to stay with child at wards for a long time. Besides, it may also affect the other siblings.

As a conclusion, the noble approach for modern management of paediatric fracture should shortened the hospital stay, comfortable, stabilize the fracture and less complication. This has led to many surgical approach to provide a better treatment for femoral shaft fracture in children. However, one should always bear in minds that the chosen method should spare the physis, not altering the vascularization of femoral head, as minimal invasive as possible and do not interfere with consolidation process or the fracture focus and stable enough as to not require additional casting for immobilization.[P. Gonzales-Herranz et al]

Reference:

1) Frech-Dörfler M, Hasler CC, Häcker F-M, "Immediate hip spica for unstable femoral shaft fractures in preschool children: still an efficient and effective option",  Eur J Pediatr Surg 2010

2) Mukesh Kalra, Asif Mahmood & Mohit K.P, "Treatment of Pediatric Femoral Shaft Fracture with Titanium Elastic Nails- Our Experience", JCOT Vol 2, No 1, 2011

3) Peter Byass & Tedros A Ghebreyesus, "Pediatric Femoral Fracture", The Lancet, Vol 365, March 2005

4) Hanne Hedina, Sune Larsson, “Technique and considerations when using external fixation as a standard treatment of femoral fractures in children. ", Injury, Int. J. Care Injured (2004) 35, 1255—1263

5) P. Berger, J.S. De Graaf, R. Leemans, " The use of elastic intramedullaey nailing in the stabilisation of paediatric fractures", Injury, Int. J. Care Injured (2005) 36, 1217-1220, Elsevier

6) P. Gonzales-Herranz, M.L.I Rodriguez  Rodriguez & M.A. Castro Torre, "Diaphyseal Femur Fractures in Children. Treatment Update", Rev esp cir ortop traumatol. 2011; 55(1): 54-66

Flying Feather: The Famous Tawau’s Street Weapon

 In the late 1940, Yutaka Katayama together with Ryuichi Romiya built flying feather. It is a car with good performance and economical value, yet a very light weight car that moves like a gull in flight. This can be also applied to another ‘flying feather’ which locally known as ‘pitik’ or ‘plem paddle’.This simple weapon is very light and sometimes just fly on the air and hit the victim without being realized until the adrenaline start to rush as the pain being perceived by the mind. 

A young man who was accidentally shot by the arrow by unknown attacker while going out from his house.

Out of nowhere, the arrow just hit his foot. the only thing he felt was intense pain and he barely can walk.

 The exact origin of this weapon is not known but with highest possibility that it is originate from Philippines. This small weapon is used in a gang fight where the purpose of this weapon is to injured the victim. Not adequate to kill the victim, but enough to bring them down so that everybody can go and beat them up with other methods. To make it more disastrous, they may put some poison at the end tip of the weapon.

 

A typical flying feather composed of nail with it's  tip is sharpened and indented at the distal end. the other end is attached with plastic rope

 

Another version of flying feather without the tail.

However, most often the shot are made by a mischievous sick-minded youngster who just enjoy doing it for fun especially when there are festivities or crowds. Therefore, many patient will presented with history of walking in specific area at the town of Tawau or simply come out from their home when they get shot. The extent of injury therefore very limited and penetrate the soft tissue. However, if the attacker intended to hurt the victim by delivering a sharp and hard blow, it can even penetrate the deeper structure injuring the vessel, nerve, penetrating the abdomen or accidentally hit the eyes. The side effect of the weapon includes dirt bring by the rusted nails or used plastic rope taken from the dump side which carry hundred of bacteria hidden from the naked eye.

 

Another random victim of the flying feather

The weapon just fly in the air and hit the victims

 This weapon is made by using simple instrument that can be found easily anywhere in the street including nail, plastic rope and rubber band. The sharp end of the nail is made flat by using a hammer first before sharpened it's tip and the distal end of it being indented  to make this weapon more difficult to be taken out as the flesh will stuck in between the curvature. Then the end of the nail will be attached to the plastic rope by using a rubber band serving to increase the velocity of the weapon as it is being shot later. The plastic rope also very helpful if the attacker just blindly shot the arrow into the air and it will randomly guide the arrow to hit the target. Some attacker will not use the plastic rope if the weapon is intended to be fire at a short distance and the arrow will straightly penetrate the victim’s body.

The sharpened and indented tip of the nail which made it easily penetrate the soft tissue and make the removal challenging.

Managing the flying feather injury may look simple but not to be taken lightly. Starting with Anti tetanus toxoid jab, health care personnel should access the extend of the injury at the bedside. Routine blood investigation should be taken as patient might be needing of surgery. The coagulation profile may give a clue as rat poison use by the attacker may impair the coagulation cascade and the total white blood cell count will raise due to infection. Simple plain X- Ray will help to evaluate further the extend of the injury and rarely other modality are needed.

Deep injury with entry and exit points

If this young man is unlucky, the weapon could just penetrate his abdomen.

 

Irrigation with copious of normal saline will help to dilute the bacterial load and reduce the infection and inflammatory agents. Proper debridement in the OT may then be needed and the wound should be left open first with daily wound dressing before it is ready for secondary suturing. Intravenous antibiotic covering for gram positive, negative and anaerobe is the next of priority together with pain management

Traumatic amputation of Finger

A three years old girl sustained injury after her left hand accidentally caught by the escalator. Picture shows complete amputation of the fifth finger and fingertip injury of the fourth finger. The radiology film shows open fracture of the distal phalanx and complete bone loss of distal and intermediate phalanx of the fifth finger.

Basically traumatic finger amputation may be divided into

1. Distal to DIP joint (Fingertip injury)

2. Proximal to DIP joint.

Objective to achieve in managing this injury

1. Reduce pain

2. Preserve sensation of fingertip

3. To help the wound heal with as little functional disability.

Simple concept

1. Amputation distal to DIP – Refashioning

2. Amputation proximal to DIP – Re implant the finger provided avaibality of equipment and skillful hand surgeon to perform hand microsurgery. Even so, patient should be warned of possibility of failed implantation and the finger will not fully functioning. In the absent of all these, re fashioning is the answer to help the wound heal.

Management of traumatic finger amputation.

1) Airway, breathing and circulation. Always remember that live first before the limb.

2) Adequate analgesia

3) Wound irrigation

4) compression bandage to stop bleeding

5) Immobilization of the injured part

6) Radiology investigation to look for the extent of injury

7) Further evaluation of the injury under digital ring block or in the operation theatre.

8) Wound debridement

9) Refashioning of the injury distal to DIP and nail bed injury.

Note: Study shows that if nail and surrounding nail margin intact, then no need to remove the nail.

10) Re implantation of finger proximal to DIP if possible

a. Clean wound

b. adequate tissue

c. availability of facility and skills for hand microsurgery

11) immobilization of the injured part either by using K-wire or simple splint depending on assesment to the patient.

12) Antibiotic

13) finger exercise.

14) KIV for skin graft if wound can not be closed.