Trauma

Trauma Case

Ext. Boonphiphop BoonphengExt. Pataramon

Case

• ผู้��ป่�วยหญิงไทย อาย� 85 ป่�• Previous status: household ambulation using

walker (Parkinson’s disease)• CC: หกล้�ม เจ็�บสะโพกซ้�าย 2 hr

Present illness

• 2 hr PTA ขณะเดินเองบนพ"#นบ�าน ม$ส�น%ขมาเกะกะ พ%นขา เส$ยหล้%กสะดิ�ดิหกล้�มเอา ก�นกระแทกพ"#นใน ท)าน%*ง ศี$รษะไม)กระแทกพ"#น ไม)สล้บ จ็-าเหตุ�การณ/ไดิ�

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Past History

Primary Survey

Physical Examination

• Vital signs: PR = 90 / min , RR = 20 /min , BP = 130/80 mmHg

• General appearance: No distress.• HEENT: not pale.• Lung: WNL• Heart: WNL

Physical examination

Right hip Left hip

- WNL

-From ASIS to medial malleolus: 71 cm

- Full ROM- Anvil: negative- Rolling: negative

- Slight external rotation- No ecchymosis. No swelling- No leg length shortening

From ASIS to medial malleolus: 70 cm- Marked tenderness at greater trochanter and lateral

leg- ROM limited in all direction due to pain- Anvil’s test: positive- Rolling test: positive- Popliteal, dorsalis pedis, posterior tibial pulse 2+- Motor power: no weakness (limited due to pain)

Upper: within normal limited both sides

Impression

• Fracture around Lt hip joint• Fracture from low-impact trauma• Osteoporosis

• Investigation:– Plain radiography of both hips: AP, lateral

Diagnosis

• Plain radiography findings:• - Intertrochanteric fracture of left hip without

displacement – Generalized osteopenia

• Final Diagnosis– Closed nondisplaced intertrochanteric fracture of

left hip– Osteoporosis

Intertrochanteric fracture

• Intertrochanteric fractures account for nearly 50% of all fractures of the proximal femur.

• Average patient age of incidence is 66 to 76 years.

• The ratio of women to men ranges from 2:1 to 8:1, likely because of postmenopausal metabolic changes in bone.

Intertrochanteric fracture

• Extracapsular fractures • occur in cancellous bone with an abundant blood supply• Low risk of nonunion/osteonecrosis but high risk of

displacement due to muscle contraction• MECHANISM OF INJURY• Intertrochanteric fractures in younger individuals are usually the

result of a high-energy injury such as a motor vehicle accident or fall from a height.

• Ninety percent of intertochanteric fractures in the elderly result from a simple fall.

• Most fractures result from a direct impact to the greater trochanteric area.

Anatomy

Evans classification

Initial management

• Pain control• Skin traction of left leg: 10 lbs• Pre-op medical consultation• Option for further management– Surgery within 72 hrs / medically stabilized– Nonoperative management– Osteoporosis management• DEXA bone mineral density measurement – baseline• Bisphosphonates / Teriparatide

Surgery

• The goal is stable internal fixation to allow early mobilization and full weight-bearing ambulation

• Most cases require surgical fixation• Fixation techniques– Sliding hip screw– Intramedullary hip screw

Nonoperative management

• Indication:– Patients at extreme medical risk for surgery– Nonambulatory patients with mild hip pain.

• Early bed to chair mobilization is important to avoid increased risks and complications of prolonged immobility

• Resultant hip deformity is both expected and accepted.

• Higher mortality rate than operative treatment.

Complication

• Loss of fixation• Nonunion• Malrotation deformity• Osteonecrosis