Extern conference Ext.พัทธวรรณ 28 กย.61

1. EXTERN
ORTHOPEDICS
CONFERENCE
Pattawan Pattanantapong, RA

2. Patient Profile
 ชายไทย 60 ปี
 ภูมิลาเนา อ. เมืองนครราชสีมา จ. นครราชสีมา
 อาชีพเกษียณ (เดิมอาชีพก่อสร้าง เลิกมา 5 ปี)

3. Chief Complaint
 ปวดต้นขาซ้าย 14 ชั่วโมงก่อนมา รพ.

4. Present Illness
 14 ชม. ก่อนมา รพ. ผู้ป่วยถูกจักรยานยนต์ล้มทับขาซ้าย มีอาการปวดที่ขา
ซ้ายมาก ขยับได้น้อย ลงน้าหนักไม่ได้ ไม่มีบาดแผลตามร่างกาย ไม่ชา ไม่
อ่อนแรง ไม่มีกระแทกบริเวณอื่น ไม่สลบ จาเหตุการณ์ได้ หลังจากนอนพัก
อาการปวดไม่ดีขึ้นจึงมา รพ.

5. Primary Survey
 A: patent airway, can talk, no c-spine
tenderness, can rotate neck
 B: trachea in midline, clear equal breath
sound both lungs, RR 16 tpm, CCT –ve
 C: BP 139/75 mmHg, PR 97 bpm, no
external active bleeding
 D: E4V5M6, pupils 2 mm RTLBE
 E: Lt. hip – externally rotated, abducted,
limited ROM due to pain

6. Secondary Survey
 A: no history of food/drug allergy
 M: current medication: Folic acid 1x1 PO pc,
Furosemide (40) 0.5x1 PO pc, Spironolactone
(25) 2x1 PO pc, Vit B Co 1x3 PO pc, Lactulose 30
mL PO prn constipation
 P: U/D decompensated alcoholic liver cirrhosis
F/U MNRH on med, last admission 11-15/7/61
presented with AoC with fever, DDx hepatic
encephalopathy, septic (UTI) encephalopathy
 L: 17.00, 20/9/61
 E: as in Present Illness

7. Physical Examination
 V/S: BT 37.3 C, BP 139/75 mmHg, PR 97
bpm, RR 16 tpm
 HEENT: mild pale conjunctivae, mild icteric
sclerae
 CVS: normal S1S2, no murmur
 Lungs: clear equal breath sound both lungs,
CCT –ve
 Abdomen: not distended, soft, not tender

8. Physical Examination
 Rt. Leg: no external
wound, localized marked
tenderness at upper
thigh, externally rotated,
abducted, limited ROM
of hip due to pain
 DPA 2+, PTA 2+,
capillary refill <2 sec.
 Pinprick sensation intact

9. Personal History
 เลิกสูบบุหรี่มา 5 เดือน
 เลิกดื่มสุรามา 5 เดือน เดิมดื่มวันละ 1-2 ขวด

10. Adjuncts to secondary survey
 Films: Pelvis AP; Lt. femur AP, lateral

11. CXR supine

12. Pelvis AP

13. Lt. femur AP, lateral

14. Lt. hip lateral

15. Both hips AP

16. Diagnosis
 Closed fracture Lt. intertrochanter

17. Management
 Admit
 On skin traction 2 kg
 Pain control
 Pre-op laboratory investigations

18. INTERTROCHANTERIC FRACTURE

19. Anatomy

20. Introduction
 Extracapsular fractures of the proximal femur
between the greater and lesser trochanters
 Most common history taking: pain around the
hip, inability to ambulate after injury
 Physical Exam: painful, shortened, externally
rotated lower extremity (greater trochanter:
abduct and externally rotated by gluteus
medius and short external rotators)

21. Introduction
 Mechanism
 Elderly: low energy falls in osteoporotic patients,
land on hip
 Young: high energy trauma

22. Introduction
Most common associated injuries
 Low enerygy fall: distal end radius fracture,
proximal humerus fracture, mild head injury
 High energy trauma: ipsilateral extremity
trauma, head injury and pelvic fracture.

23. Introduction
 20-30% mortality risk in the first year
 Factors that increase mortality
 higher in intertrochanteric fracture (vs. femoral
neck fracture)
 operative delay of >2 days
 age >85 years
 2 or more pre-existing medical conditions
 ASA classification III and IV increases mortality

24. Laboratory Investigations
 Routine pre-op lab.
 Osteoporosis: vit D, PTH, TSH
 Malnutrition and vitamin D deficiency: serious
risk factors for mortality and recovery
 Current recommendations; administer 50,000
IU of Vit. D immediately to all elderly patients
on admission with hip fracture

25. Imaging
 Pelvis AP
 Hip AP, lateral cross table
 Femur AP, lateral
 CT or MRI

26. Classification: Boyd & Gryffin
Treatment recommendation classification
Type 1 : Simple
Type 2 : Posteromedial comminution
Type 3 : Reverse obliquity
Type 4 : Subtrochanteric extension

27. Stability
 Stable
 intact posteromedial cortex
 will resist medial compressive loads once
reduced
 Unstable
 Reverse obliquity pattern
 Posteromedial comminution
 Displaced GT (lateral wall fracture)
 Subtrochanteric extension
 Coronal split

28. Management
Surgery vs. Conservative
 Surgery: greater pain relief, improved early
patient mobility, lower mortality rate
 Non-operative management indications
 Non ambulatory or chronic dementia
 Terminal disease, < 6 wks life expectancy
 Unresolvable medical comorbidites

29. Non-operative Management
 Nonweightbearing with early out of bed to
chair
 Skin traction for 6 weeks, then lift into wheel
chair or reclining chair
 Frequent positioning, nutritional support, fluid
homeostasis, adequate pain control
 high rates of pneumonia, UTI, pressure sore,
DVT

30. Operative Management
 Recommend early surgery within 24-48 hrs
(decreased hospitalization time, reduced post-
op complications)

31. Operative Management
Sliding hip compression
screw
 indications
 stable type
 outcomes
 equal outcomes when
compared to intramedullary
hip screws for stable fracture
patterns

32. Operative Management
Intramedullary hip screw
(cephalomedullary nail) indications
 stable fracture patterns
 unstable fracture patterns:
 Reverse obliquity pattern
 Posteromedial comminution
 Displaced GT (lateral wall fracture)
 Subtrochanteric extension
 Coronal split

33. Operative Management
Arthroplasty Indications
 severely comminuted fractures
 preexisting symptomatic degenerative arthritis
 osteoporotic bone that is unlikely to hold internal
fixation
 salvage for failed internal fixation

34. Post-op Complications
 Thromboembolic phenomenon
 Infection
 Non union/malunion
 Implant failure and cut-out
 Anterior perforation of the distal femur
(intramedullary screw fixation)

35. Thank you for your attention