This document describes the case of a 69-year-old Thai man who presented to the emergency department with right thigh pain after falling 1.5 meters from the roof of his house. On examination, he had swelling and tenderness of the left thigh with limited range of motion. Radiographs revealed an intertrochanteric fracture of the left femur. Intertrochanteric fractures occur between the greater and lesser trochanters and are common in elderly patients, often resulting from low-energy falls. Treatment depends on the stability of the fracture but may involve internal fixation with screws or cephalomedullary nails. Complications can include malunion, nonunion, and loss of fixation.

1. EXTERN CONFERENCE
Extern Thanakrit Visuthigosol

2. Patient profile
• ผู้ป่วยชายไทย อายุ 69 ปี
• ภูมิลาเนา อาเภอโนนไทย จังหวัดนครราชสีมา
• No underlying disease

3. CC: ปวดต้นขาขวา 5 ชั่วโมง PTA
• PI: 5 ชั่วโมงก่อนมาโรงพยาบาล ผู้ป่วยลื่นตกจากหลังคาบ้าน สูงประมาณ
1.5 เมตร ล้มเอาขาขวากระแทกยันพื้น ศีรษะไม่กระแทกพื้น ไม่สลบ หลัง
ล้ม เดินไม่ได้ ต้นขาขวาผิดรูป ไม่มีบาดเจ็บบริเวณอื่น

4. Primary survey
• A: Patent airway, C - spine not tender
• B: Clear breath sound equal both lungs, CCT
negative
• C: BP 100/66 mmHg, PR 92 /min
• D: E4V5M6, pupil 3 mm RTLBE
• E: Left thigh swelling and marked tender.
Limit ROM at left thigh and knee due to pain.
T-L, L-S spine not tender

5. Secondary survey
• Allergy: no food or drug allergy
• Medication: no current medication
• Past history: No underlying disease
• Last meal: NPO 9.00 AM
• Event/Exposure: ตกจากหลังคาบ้าน 1.5m

6. Physical examination
• V/S: BP 100/66 mmHg, PR 92 bpm, RR 18 /min, BT
36.6 c
• GA: A Thai elderly, good consciousness.
• HEENT: Not pale conjunctiva, anicteric sclera.
• Heart: Normal S1, S2, no murmur.
• Lung: Clear, equal breath sound both lungs.
• Abdomen: Soft, not tender.
• Extremities: As page below.

7. • Left leg
• ดู Left thigh swelling, no external wound, shortening of
left leg.
• คลา tender at left thigh.
• ขยับ วัด: Limit ROM due to pain (flexion, extension,
abduction, adduction)
• Neurovascular test: Popliteal artery 2+, Posterior tibial
artery 2+, Dorsalis pedis artery 2+, Capillary refill < 2
sec.
• Motor grade V all extremities except Left hip motor,
grade at least IV+ due to pain
• Normal pinprick sensation

9. Investigation

11. INTERTROCHANTERIC
FRACTURES

12. Intertrochanteric fractures
• Fracture between
greater trochanter and
lesser trochanter in the
intertrochanteric line

13. Etiology
• Common in elderly.
• Mostly related with osteoporotic patient.
• Mechanism
• Elderly (90%)
• Low energy falls in osteoporotic patients.
• Young (10%)
• High energy trauma.

14. Clinical feature
• Patient usually can’t move
after trauma.
• Pain at proximal thigh.
• Progressive pain when flex
hip and external rotate lower
extremity.
• Shortened thigh
• Ecchymosis.
• Swelling

15. Investigation
• 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

16. Evan’s
classification

17. Evan’s
classification
• We divide Evan’s
classification in 2
types, “Stable” and
“Unstable”
• Stable
• intact
posteromedial
cortex
• Unstable

18. Non-operative management
• Non-weightbeating with early out of bed to
chair
• High rates of pneumonia, UTI, DVT,
Infection.
• Indication
1. Stable type
2. Non-ambulatory patient
3. Patient with high risk of perioperative
mortality

19. Operative management
• sliding hip compression screw
• Stable intertrochanteric fracture.
• intramedullary hip screw (cephalomedullary nail)
• arthroplasty
1. severely comminuted fractures
2. preexisting symptomatic degenerative arthritis
3. osteoporotic bone that is unlikely to hold internal fixation
4. salvage for failed internal fixation

21. Complication
• Malunion
• Nonunion
• Loss of fixation