This document describes an elderly Thai woman who fell and injured her left hip. She was unable to walk after the fall. Physical examination found shortening and external rotation of her left leg with tenderness over the proximal thigh. Imaging showed an intertrochanteric fracture of the left femur. She was admitted and placed on skin traction. Surgical treatment options for this type of hip fracture include dynamic hip screw or intramedullary hip screw depending on fracture stability. Complications can include implant failure, perforation of the distal femur, nonunion, or malunion.

1. Extern conference
Ext.Nunticha Chuenpakorn
Ramathibodi 5602075

2. History
• หญิงไทยคู่อายุ 72 ปี
• CC : ล้มก้นกระแทกพื้นมา 4.5 ชม.

3. History
• PI : ผู้ป่วยให้ประวัติว่าลื่นล้มเอง ก้นกระแทกพื้น ไม่มีศีรษะกระแทกพื้น ไม่สลบ จา
เหตุการณ์ได้ เจ็บสะโพกข้างซ้าย หลังล้มเดินไม่ได้
• U/D DM, HT, DLP, CKD stage4

4. Physical examination
• v/s : BP153/70mmHg, PR 64/min, RR 20/min
• ABC – Pass
• GA : A Thai elderly woman, alert, good consciousness
• Lung : normal breath sound equal both lungs
• CVS : normal S1S2, no murmur
• Abdomen : soft, not tender, no guarding
• Extremities : Lt shortening leg (90, 93 cm), external rotation,
tender at proximal thigh, limit hip motion due to pain
other joints full ROM, Lt. PTA&DPA 2+

5. DDx
• Fracture of neck femur
• Fracture of intertrochanter
• Fracture of subtrochanter
• Fracture of femoral shaft
• Hip dislocation

6. Imaging

9. At ER
• Admit and on skin traction

10. Imaging after skin traction

12. Intertrochanteric fracture

13. Anatomy of hip

14. Cause of fracture
• Elderly : Fall from height (osteoporosis)
• Teenage : Pathologic fracture

15. Sign and symptom
• Pain at medial to greater trochanter (proximal thigh)
• Deformity – external rotation
• Shortening leg
• Pain on active and passive movement

17. Evan classification
• Stable
o intact posteromedial cortex
• Unstable
o comminution of the posteromedial cortex
o fractures with a large posteromedial fragment : lesser trochanter
o Reverse oblique : oblique fracture line extending from medial cortex both laterally and
distally

18. Treatment
• Non operative care
o Skin traction
o nonweightbearing with early out of bed to chair
o 12-16 weeks until bone union
o indications
• nonambulatory patients
• patients at high risk for perioperative mortality
o outcomes
• high rates of pneumonia, urinary tract infections, decubiti, and DVT

19. Treatment
• Dynamic hip screw
o indications
• stable intertrochanteric
fractures

20. • intramedullary hip screw
o indications
• stable fracture patterns
• unstable fracture patterns
• reverse obliquity fractures
• subtrochanteric extension
• lack of integrity of femoral wall

21. Complication
• Implant fail (most common)
• Anterior perforation of distal femur
• Nonunion
• Malunion