คคคคคคคคคคคคค คค.คคคคคคคคค คค.คคคคคคคคคคคคคคคค คคคคคคคคคคคคคคคค คคคคคคคคค Ext. คคคคค คคคคคคคคคคคคคค คคคคคคคคคค 2559 คคคคคคคคคคค2 Orthopaedic Teleconference
คณะแพทยศาสตร รพ.รามาธบดรพ.มหาราชนครราชสมา
มหาวทยาลยมหดล
จดทำาโดย Ext. วราพร หวงวบลยชย ปการศกษา2559 ภาคเรยนท2
Orthopaedic Teleconference
Patient profile
ผปวยหญงไทยค อาย 92 ป ปจจบนไมไดประกอบ อาชพ
ภมลำาเนา จ.นครราชสมา
ปวดสะโพกขวา 2 ชม.กอนมารพ.
Chief complaint
• 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
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
Secondary SurveyHistory Taking Allergy : none Medication : none Past Illness : no underlying disease Last meal : 16.00 น.
Secondary Survey
Event : 2 ชม.กอนมารพ. ผปวยลนลมขณะ เดน สะโพกขวากระแทกพน ไมมอาการหนามด ใจ
สน ชกเกรงกระตกกอนลม ไมมศรษะกระแทก จำา เหตการณได หลงลมปวดบรเวณสะโพกขวา
ลกยนไมได
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
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)
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
swelling at Rt. hip
Film pelvis AP
Film right hip
lateral
Diagnosis
Closed fracture Rt. intertrochanter
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
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
Intertrochanteric Fracture Physical Exam
tenderness, ecchymosis at greater trochanter
shortened lower extremity externally rotated lower extremity
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
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
Management
2. Operative 2.1 ). ORIF
Indications -stable fracture patterns-unstable fracture patterns -reverse obliquity fractures -subtrochanteric extension
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
Complication
1. Nonunion (<2%)2. Malunion - varus and rotational deformities are common3. Loss of fixation
Film both hip AP
Post-op film
Film right hip lateral
Post-op film
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