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- 1. Interesting case 13 July 2017 Guntarat Chinvattanachot Faculty of medicine Ramathibodi hospital
- 2. A Thai man, 20 years old Motorcycle accident 30 minutes PTA
- 4. Primary survey Airway and C-spine protection can speak , no stridor able to achieve neck movements all directions without pain , not tender along posterior cervical midline , absence of focal neurological deficit , no evidence of alcohol intoxication , absence of distracting painful injury Breathing no open chest wound , RR 22/min , trachea in midline , equal chest movements and equal breath sound both lungs , chest compression test negative , absence of paradoxical movement of chest wall , neck vein not engorged
- 5. Primary survey Circulation vital signs : BP 119/60 mmHg , Pulse rate 130 bpm , no active bleeding , pelvic compression test negative , not tender at both thighs Disability E4V5M6 pupil 2.5 mm RTLBE
- 6. Primary survey Exposure multiple abrasion wounds at right knee and both arms marked swelling at left forearm , tender at mid forearm , no obvious deformity deformity of right leg as shown in the picture no wound at back , not tender along spine
- 7. Adjunct to primary survey Film chest x-ray Film pelvis AP FAST
- 8. Secondary survey Allergies : deny history of food and drug allergy Medication : no current medication Past illness : no known underlying disease Last meal : 8.00 Event : motorcycle crash with a car
- 9. Physical examination General appearance : A Thai adolescent man, alert, oriented to time place person HEENT : no wound on scalp and face, no periorbital ecchymosis, no abnormal discharge from ears or nose Cardiovascular : pulse full regular all extremities , no distant heart sound , normal S1 S2 , no murmur Respiratory : clear , equal breath sound both lungs , no adventitious sound
- 10. Physical examination Abdomen : no ecchymosis , soft , not tender , no guarding , no rebound tenderness Neurologic : alert , active , oriented to time place person , E4V5M6 , pupils 2mm RTLBE motor V/V (could not evaluate left arm and right leg due to pain) , sensory intact , DTR 2+
- 11. Physical examination Extremities : Right arm and Left leg : no deformity , presence of small abrasion wounds , not tender , full active ROM , intact sensation , pulse 2+ Left arm : marked swelling at left forearm , no obvious deformity , tender at mid forearm , limit elbow and wrist ROM due to pain , full ROM of fingers , intact sensation , radial pulse and ulnar pulse 2+
- 12. Physical examination Right leg : deformity as shown in the picture , tender at buttock area , not tender and groin thigh knee ankle and foot , no stepping limit active hip and knee ROM due to pain , passive ROM was not evaluated able to perform ankle dorsiflexion plantarflexion inversion and eversion , able to perform toes dorsiflexion plantarflexion abduction and adduction intact pinprick sensation dorsalis pedis pulse and posterior tibial pulse 2+
- 13. Adjunct to primary survey
- 14. Investigation
- 18. Problem lists Mild head injury ( Moderate risk) R/O blunt abdominal injury Posterior dislocation of right hip Closed fracture mid shaft of left radius
- 20. Hip dislocation Posterior hip dislocation Anterior hip dislocation Central hip dislocation
- 23. Deformity
- 28. Classification
- 29. Classification
- 30. Management
- 31. Pre reduction considerations Associated injuries and fractures Neurologic and vascular injury
- 32. Close reduction
- 35. Post reduction management Stability Neurovascular assessment Congruency • Plain film : 5 standard views Both hip AP , Judet views , inlet and outlet of pelvis • CT scan
- 38. Post reduction management Immobilization Pain control
- 39. Post reduction management Rehabilitation • Limit adduction , internal rotation , flexion < 60 degree • Exercise abduction, extension • Early mobilization • Partial weight bearing with gait aid 4-6 weeks
- 40. Operative management Indications • Associated fractures : acetabulum , femoral head , femoral neck • Irreducible dislocation • Iatrogenic sciatic nerve injury • Incongruent reduction
- 41. Late complications Avascular necrosis Arthritis Heterotopic ossification Sciatic nerve dysfunction
- 42. AVN early detection :Lack of disuse osteopenia (no resorption) relatively sclerosis -> further MRI Mx : core decompression (early treatment )