extern conference 50859
TRANSCRIPT
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Extern conference 5/08/59Extern ภวูเดช ศรสีนัติสขุ
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Patient profile
ผู้ป่วยชายไทย อายุ 54 ปี ภมูลิำาเนา อำาเภอเมอืง จงัหวดันครราชสมีา อาชพี วา่งงาน สทิธบิตัรทอง
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History
CC: เจบ็สะโพกขวาหลังอุบติัเหตุ 14 ชัว่โมงก่อนมารพ. Primary survey
A: can speak, no cervical tenderness, full ROM of neck B: Equal BS, CCT –ve C: BP 113/60 mmHg, PR 77/min D: E4V5M6, pupil 3mm RTL both eyes E: no external wound
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Secondary survey A: no drug allergy M: no current medication P: no U/D L: last meal 6hr.PTA E: 14 hr.ก่อนเมาสรุาล่ืนล้มเอง ก้นกระแทกพื้น หลังจาก
นัน้มอีาการปวดที่บรเิวณสะโพกขวา ขยบัขอ้สะโพกขวาแล้วเจบ็ เดินไมไ่ด้ สะโพกซา้ยปกติ ไมม่ชีา ขยบันิ้วเท้า/ขอ้เท้าได้ปกติ ไมม่ปีวดบรเิวณอ่ืน ไมม่ไีข ้ไมม่เีบื่ออาหาร ไมม่นีำ้าหนักลด
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Physical examination
Vital sign: BP 113/60 mmHg, PR 77/min, RR 16/min, T 36.8 C
GA: A Thai man, good consciousness, well co-operative
HEENT: not pale conjunctiva, anicteric sclera Lung: Equal and normal breath sounds Heart: normal S1 S2, no murmur Abdomen: soft, not tender
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Extremities
No wound, mild swelling, no deformitytenderness at Rt. HipLimit ROMAvrill +veRolling +veNo numbnessDTA 2+, PTA 2+
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Investigation
Film Hip AP, lateral
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Diagnosis
Right intertrochanteric fracture
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Fracture of Proximal femur แบง่ได้เป็น 3 กลุ่ม คือ1. Fracture neck of the femur เริม่จาก
anatomical neck ถึงบรเิวณ just proximal ต่อ intertrochanteric line เป็น intracapsular fracture
2. Intertrochanteric fracture รอยหกัผ่าน intertrochanteric line เป็น extracapsular fracture
3. Subtrochanteric fracture รอยหกัผ่านบรเิวณ lesser trochanter และตำ่าลงไปอีก 5 ซม.
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1. Fracture neck of the femur
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Management
Immobilize and refer Operation
internal fixation (ORIF) cannulated screw fixation
sliding hip screw Hemiarthroplasty total hip arthoplasty
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2. Intertrochanteric fracture
In stable fractures, the lesser trochanter is not displaced, no comminution, the medial cortices of the proximal and distal
fragments are in alignment. In unstable fractures,
displacement occurs, comminution is present, multiple fracture lines exist.
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Management
Skin traction 6 week Compilcation: venous thrombosis, pressure sore,
pneumonia, UTI operation
sliding hip compression screw
intramedullary hip screw
arthroplasty
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Non displaced มกัจะม ีdisplacement ในภายหลังจงึนิยมรกัษา
โดยการผ่าตัดยดึด้วยสกรู 2-3 ตัว Displaced
ในคนหนุ่มสาว ทำา closed reduction และ multiple screw fixation
ในคนสงูอายุที่ม ีosteoporosis ควรผ่าตัดเปล่ียนหวักระดกูสะโพก(hemiarthroplasty)
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Prognosis nonunion and malunion rates are low 20-30% mortality risk in the first year following
fracture factors that increase mortality
male gender (25-30% mortality) vs female (20% mortality)
higher in intertrochanteric fracture (vs femoral neck fracture)
operative delay of >2 days age >85 years 2 or more pre-existing medical conditions ASA classification (ASA III and IV increases mortality)
surgery within 48 hours decreases 1 year mortality
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3. Subtrochanteric fracture
Russel-Taylor Classification Type I: No extension into piriformis fossa Type II: Extension into greater trochanter
with involvement of piriformis fossa • look on lateral x-ray to identify piriformis fossa extension
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In younger patients with a high-energy mechanism may occur
In elderly patients from a low-energy mechanism rule out pathologic or atypical femur
fracture bisphosphonate use, particularly
alendronate, can be risk factor
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Treatment
high energy trauma จะรกัษาโดย internal fixation metastatic cancer ผ่าตัดเอาเนื้องอกออกนำาชิน้เนื้อมาตรวจ และ
ทำา internal fixation และอาจจะเสรมิความแขง็แรงด้วย bone cement
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Thank you