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TOGETHER AS ONE

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TOGETHER AS ONE

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  1. TOGETHER AS ONE Bolintiam, Cruz, dela Cruz, Lu, Que, Rivera, Sioco, Tai, Valera, Veloso

  2. Identifying Data • ML • 15 F • Mandaluyong City • RC • Student • Right handed

  3. Chief Complaint “Hindi maigalawmabutiangkaliwangbraso” (limitation of movement of the left arm)

  4. HPI • Playing on top of a rolling drum • Fell with an outstretched left arm • (+) limp L arm 14 months PTA (October 2011)

  5. HPI • (+) swelling, gross deformity • (-) open wound • (-) numbness and other sensory deficits • “Hilot” for two months 14 months PTA (October 2011)

  6. HPI • No improvement of symptoms • Limitation of flexion of elbow to only about 30deg • Sought consult in POC • X rays were done 12 months PTA

  7. XRAY

  8. XRAY

  9. XRAY

  10. XRAY

  11. XRAY

  12. Elbow X Ray (AP)

  13. Elbow X Ray (Oblique)

  14. Elbow X Ray (Lateral)

  15. HPI • No improvement of symptoms • Limitation of flexion of elbow to only about 30deg • Sought consult in POC • Xray • Advised to follow-up after 6 months 12 months PTA

  16. HPI 6 months PTA • On follow-up: • Advised surgery • Referred to another institution • Deferred

  17. HPI 1 month PTA • Patient sought consult with attending physician and was advised surgery • Referred to DM ADMISSION

  18. Past Medical History • No asthma, lung, heart, kidney, liver and other congenital diseases • No previous hospitalizations • No previous surgeries • No allergies to food and medications

  19. Immunization • DPT x 3 • OPV x 3 • Hep B x3 • BCG • Measles

  20. Developmental History • At par with age • Cognition, motor, verbal

  21. Functional History (Activities of Daily living ) Prior to accident After accident Difficulty in Bathing Dressing Grooming Eating • Bathing • Dressing • Grooming • Oral care • Toileting • Transferring • Eating

  22. Functional History(Instrumental Activities of Daily living) Prior to accident After accident Difficulty in Food preparation Housekeeping Laundry • Shopping • Food preparation • Housekeeping • Laundry • Transportation • Finances

  23. Family History

  24. Family History • (+) Diabetes- father of patient, osteoporosis- grandmother of patient • (-) Hypertension, Dyslipidemia, Stroke, MI, Cardiac Problems, Renal Problems, Cancer, Asthma

  25. Personal and Social History • Non-smoker • Non-alcoholic beverage • No illicit drug use

  26. Personal and Social History (HEADSSS) • Home • Close to family • Education • Incoming 1st year high school student • Forced to stop school this year • Activities • Loves to watch TV • Diet • 3 meals: rice and meat • Suicide • None • Sex • None • Substance • None

  27. Review of Systems • General: (-) fever, weight loss, loss of appetite • Musculoskeletal/Derma: No skin lesions or changes • HEENT: (-) history of head injury. (-) BOV, tinnitus, epistaxis, (-)dysphagiaor enlarged lymph nodes • Respiratory: (-) cough or colds, wheezing, hemoptysis • Gastrointestinal: (-) abdominal pain, changes in bowel habits, diarrhea, or constipation • Genitourinary: (-) dysuria or hematuria,

  28. Physical Exam • Awake, alert, coherent • Vitals: • 42 kg, 142; BMI 18.2 Normal • BP 100/60 • HR 86 • RR 19 • Temp 36.4 • Not in pain (0)

  29. PHYSICAL EXAMINATION

  30. PHYSICAL EXAMINATION

  31. PHYSICAL EXAMINATION

  32. Salient Features

  33. Differentials • Extension fracture of the supracondylar humerus

  34. Differentials • Flexion fracture of the supracondylarhumerus

  35. Differentials • Elbow Joint Dislocation (Posterior)

  36. Differentials • Juvenile Idiopathic (Rheumatoid) Arthritis

  37. Differentials • Malignancy: Osteosarcoma

  38. Working Impression Malunion of the left elbow probably secondary to neglected supracondylar humerus fracture

  39. Anatomy of the elbow

  40. Humerus • Capitulum (lateral)  radial head • Trochlea (medial)  trochlear notch of the ulna • Anterior Coronoidfossa  receives coronoid process of ulna during full flexion • Posterior Olecranonfossa  receives olecranon of ulna during extension • Radial fossa  receives edge of head of radius during full flexion

  41. Ulna • Stabilizing bone • Located medially, longer • Articulation between ulna and humerus flexion, extension (with minimal abduction and adduction during pronation- supination) • Tapers at the end to form the ulnar head and the styloid process • Doesn’t reach and participate in joint action

  42. Radius • Head of the radius and capitulum flexion and extension of the elbow

  43. Muscles

  44. Muscles

  45. Supracondylar Humerus Fractures • Fractures of the distal humerus just above the epicondyles • Typically remains extra articular • 55% to 75% of all elbow fractures • Peak incidence  5 to 8 years, after which dislocations become more frequent • The left, or nondominant side, is most frequently injured

  46. Supracondylar Fractures • In 5 – 8 year olds, bone remodeling causes a decreased anteroposterior diameter in the supracondylar region, making this area susceptible to injury • Ligamentous laxity in this age range  increased likelihood of hyperextension injury • The anterior capsule is thickened and stronger than the posterior capsule. • In extension: the fibers of the anterior capsule are taut, serving as a fulcrum by which the olecranon becomes firmly engaged in the olecranon fossa • With extreme force: hyperextension may cause the olecranon process to impinge on the superior olecranon fossa and supracondylar region • The periosteal hinge remains intact on the side of the displacement