orthopaedic teleconference

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คคคคคคคคคคคคค คค.คคคคคคคคค คค.คคคคคคคคคคคคคคคค คคคคคคคคคคคคคคคค คคคคคคคคค Ext. คคคคค คคคคคคคคคคคคคค คคคคคคคคคค 2559 คคคคคคคคคคค2 Orthopaedic Teleconference

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Page 1: Orthopaedic teleconference

คณะแพทยศาสตร รพ.รามาธบดรพ.มหาราชนครราชสมา

มหาวทยาลยมหดล

จดทำาโดย Ext. วราพร หวงวบลยชย ปการศกษา2559 ภาคเรยนท2

Orthopaedic Teleconference

Page 2: Orthopaedic teleconference

Patient profile

ผปวยหญงไทยค อาย 92 ป ปจจบนไมไดประกอบ อาชพ

ภมลำาเนา จ.นครราชสมา

Page 3: Orthopaedic teleconference

ปวดสะโพกขวา 2 ชม.กอนมารพ.

Chief complaint

Page 4: Orthopaedic teleconference

• A : airway-patent, no C-spine tenderness

• B : no dyspnea, trachea in midline, equal breath sound, no

adventitious sound both lungs, no neck v. engorged,

no distance heart sound, ribs - not tender, no stepping, no open wound on chest wall

Primary Survey

Page 5: Orthopaedic teleconference

Primary Survey C : BP 172/ 80 mmHg, P 94 bpm with full

regular pulses, capillary refill < 2 sec, no external active bleeding, pelvic compression test – negative

D : pupil 3 mm RTLBE, E4V5M6

E : ecchymosis 3 x 4 cm and tendernessat right greater trochanter,PR - not done

Page 6: Orthopaedic teleconference

Secondary SurveyHistory Taking Allergy : none Medication : none Past Illness : no underlying disease Last meal : 16.00 น.

Page 7: Orthopaedic teleconference

Secondary Survey

Event : 2 ชม.กอนมารพ. ผปวยลนลมขณะ เดน สะโพกขวากระแทกพน ไมมอาการหนามด ใจ

สน ชกเกรงกระตกกอนลม ไมมศรษะกระแทก จำา เหตการณได หลงลมปวดบรเวณสะโพกขวา

ลกยนไมได

Page 8: Orthopaedic teleconference

Secondary SurveyHead to toe examination GA : A Thai old woman, good conciousness

not pale, no jaundice, no dyspnea HEENT : no pale conjunctivae, anicteric sclera CVS : full regular pulse, no carotid bruit

normal S1 S2, no murmur Respiratory : equal breath sound,

no adventitious sound

Page 9: Orthopaedic teleconference

Secondary Survey GI : soft, normoactive bowel sound

not tender, no guarding/rebound tenderness

Extremities - inspection : marked swelling, ecchymosis 3 x 4 cm., at right greater trochanter- palpation : tenderness at right greater trochanter- limit ROM of Rt hip due to pain (flexion, extension, abduction, adduction, rotation)

Page 10: Orthopaedic teleconference

Secondary Survey

- special test : Anvil and Rolling positive at right leg- neurovascular :

full Rt. Dorsalis pedis a., Posteriot tibial a., Popliteal a.

capillary refill < 2 secmotor power of Rt. plantar flexion,

dorsiflexion grade V

Page 11: Orthopaedic teleconference

swelling at Rt. hip

Page 12: Orthopaedic teleconference

Film pelvis AP

Page 13: Orthopaedic teleconference

Film right hip

lateral

Page 14: Orthopaedic teleconference

Diagnosis

Closed fracture Rt. intertrochanter

Page 16: Orthopaedic teleconference

Extracapsular fractures of the proximal femur between the greater and lesser trochanters

Mechanism 1.elderly - low energy falls in osteoporotic patients2.young - high energy trauma

Intertrochanteric Fracture

Page 17: Orthopaedic teleconference

Intertrochanteric Fracture Prognosis

nonunion and malunion rates are low 20-30% mortality risk in the first year following

fracture factors that increase mortality

- 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 

Page 19: Orthopaedic teleconference

Imaging Radiographs

- AP pelvis- AP of hip, cross table lateral- full length femur radiographs

CT or MRI useful if radiographs are negative but physical exam consistent with fracture

Page 20: Orthopaedic teleconference

Management1. Nonoperative – “skin traction” 4-6 weeks

Indications - nonambulatory patients- patients at high risk for perioperative mortality Outcomes - high rates of pneumonia, urinary tract infections, pressure sore, and DVT

Page 21: Orthopaedic teleconference

Management

2. Operative 2.1 ). ORIF

Indications -stable fracture patterns-unstable fracture patterns -reverse obliquity fractures -subtrochanteric extension

Page 22: Orthopaedic teleconference

Intertrochanteric Fracture

2.2 ). arthroplasty

Indications -severely comminuted fractures-preexisting symptomatic degenerative

arthritis-osteoporotic bone that is unlikely to

hold internal fixation-salvage for failed internal fixation

Page 23: Orthopaedic teleconference

Complication

1. Nonunion (<2%)2. Malunion - varus and rotational deformities are common3. Loss of fixation

Page 24: Orthopaedic teleconference

Film both hip AP

Post-op film

Page 25: Orthopaedic teleconference

Film right hip lateral

Post-op film

Page 26: Orthopaedic teleconference

References ธรชย อภวรรธกกล.Orthopaedic Trauma.พมพ

ครงท 5. คณะแพทยศาสตร มหาวทยาลยเชยงใหม นรเทพ กลโชต.Hip fracture-dislocation and

fracture femur. คณะแพทยศาสตร รพ. รามาธบดมหาวทยาลยมหดล

http://www.orthobullets.com/trauma/1038/intertrochanteric-fractures

http://emedicine.medscape.com/article/1247210-treatment#d9

http://orthoinfo.aaos.org/topic.cfm?topic=A00392