Extern conference Ext.ธนกฤต   14 มค.62

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