Download - Noon conf. [Ext.Worawan]
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EXTERN NOON CONFERENCE
ext. วรวนท เจยตระกลโรงพยาบาลรามาธบด
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CHIEF COMPLAINT
ผปวยชายไทย อาย 35 ป ขาผดรป 4 ชวโมงกอนมาโรงพยาบาล
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PRIMARY SURVEY A : Can speak, c-spine not tender, full ROM B : Clear breath sound equal both lungs, trachea in midline, CCT negative
C : BP 103/69mmHg, Pulse 100 bpm, capillary refill time < 2 sec, no active bleeding
D : E4V5M6, pupils 3 mm RTLBE E : No external wound
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SECONDARY SURVEY A : No history of food and drug allergy M : No current medications P : HBV carrier L : 21:00 (8.5 hr PTA) E : 4 hr PTA ผปวยขบรถกระบะลงคนำ(าขางทาง เขาท(งสองขางชนคอนโซล
หนารถ เขาท(งสองขางตดอยใตคอนโซล หลงพยายามเอาขาออกจาก คอนโซล ขาขวาผดรป ปวดบรเวณสะโพกขวา ขยบสะโพกขวาไมได เดนไมได
มประวตดมสรา ปฎเสธประวตศรษะกระแทก จำาเหตการณได ไมสลบ ไมม ปวดศรษะ ปฎเสธอก/ทองกระแทก
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HEAD TO TOE EXAMINATION GA : Good consciousness, not pale, no jaundice VITAL SIGN : BT 37C, BP 103/69 mmHg, Pulse 100 mmHg, RR 16 times/min
HEENT : No pale conjunctiva, anicteric sclera HEART : Full regular pulse, normal s1 s2 no murmur LUNGS : Clear equal both lungs, no adventitious sound ABDOMEN : No distension, normoactive bowel sound, soft, not tender
EXT. : as picture
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Inspection : Rt. Hip – flexion & adduction & internal rotation
Abrasion wound at Lt. knee Palpitation : Tender at Rt. Hip Range of motion : limit ROM of Rt. Hip Neurovascular : Normal sensation, can dorsiflexion and plantar flexion DPA 2+
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FILM BOTH HIP AP
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DIAGNOSIS # Posterior Right hip dislocation # Mild head injury (Moderate risk)
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(POSTERIOR) HIP DISLOCATION
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OUTLINE Epidemiology Anatomy Classification Presentation Imaging Management Complications
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EPIDEMIOLOGY RARE ! Most commonly dislocated joint of the lower extremity, with incidence of 5.2% Male : Female = 4 : 1 Mechanism is usually young patients with high energy trauma
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ANATOMY
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BLOOD SUPPLY
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EMERGENCY CONDITION !!
Multiple traumaAvascular necrosis
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TYPE Simple : pure dislocation without associated fracture
Complex : dislocation associated with fracture of acetabulum or proximal femur
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ANATOMIC CLASSIFICATION Posterior dislocation (90%) occur with axial load on femur, typically with hip flexed and adducted axial load through flexed knee (dashboard injury)
Anterior dislocation (10%) occurs with the hip in abduction and external rotation
Central dislocation caused by a lateral force against an adducted femur always a fracture-dislocation
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PRESENTATION Symptoms : acute pain, deformity, inability to move the hip joint, inability to bear weight
Physical exam : HIP >>> flexion, adduction, and internal rotation examine knee for associated injury or instability neurovascular exam (10-20% sciatic nerve injury)
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SCIATIC NERVE Common peroneal (fibular) nerve Sensation : lateral side of the lower leg and upper surface of the foot
Motor : dosiflexion
Tibial nerve Sensation : sole of the foot Motor : plantar flexion
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IMAGING Radiographso Shenton's line brokeno femoral head smaller than contralateral sideo lesser trochanter shadow reveals internally rotated limb as compared to contralateral side
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IMAGING CTpost reduction CT must be performed for all traumatic hip dislocations to look for femoral head fractures, loose bodies, acetabular fractures
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MANAGEMENTNon-operative : Emergent closed reduction within 6 hr
Allis maneuver Stimson maneuver Bigelow maneuver
Operative
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ALLIS MANEUVER
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STIMSON MANEUVER
contraindicated in the setting of thoracoabdominal trauma or a difficult airway.
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BIGELOW MANEUVER
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OPERATIVE Indications• Irreducible dislocation (approximately 10% of all dislocations)• Persistent instability of the joint following reduction (eg, fracture-dislocation of the posterior acetabulum)• Fracture of the femoral head or shaft• Neurovascular deficits that occur after closed reduction
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COMPLICATIONS Post-traumatic arthritis up to 20% for simple dislocation, markedly increased for complex dislocation If an associated acetabular fracture is present, the incidence of traumatic arthritis is as high as 80%.
Femoral head osteonecrosis 5-40% incidence Increased risk with increased time to reduction
Sciatic nerve injury 8-20% incidence associated with longer time to reduction
Recurrent dislocations less than 2% Risk factors for recurrent dislocation are large capsular defects, intra-articular fragments, or a prosthetic hip.
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MANAGEMENT IN THIS PATIENT CT Brain non-contrast Set OR for close reduction under GA Test stability 30, 60, 90 Repeat film after reduction Repeat neurovascular examination On skin traction 2 kg.
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FILM S/P CLOSED REDUCTION
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REFERENCES www.orthobullets.com emedicine.medscape.com Hip fracture -dislocation and fracture femur, นพ. นรเทพ กลโชต, โรงพยาบาลรามาธบด
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