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Extern conference ortho
- 1. EXTERN CONFERENCE EXTERN NATCHA HOMROSSUKHON PHRAMONGKUTKLAO COLLEGE OF MEDICINE
- 2. CASE HISTORY • ผู้ป่วย หญิง ไทยคู่ อายุ 76 ปี • ภูมิลาเนา จ.นครราชสีมา • สัญชาติไทย ศาสนาพุทธ • Mechanism of Injury หกล้ม • เหตุเกิดเมื่อ 2 มค. 2561
- 3. CHIEF COMPLAINT • ปวดสะโพกซ้าย 1 วันก่อนมาโรงพยาบาล
- 4. PRESENT ILLNESS • 1 วันก่อนมาโรงพยาบาล ผู้ป่วยสะดุดล้มขณะที่กาลังจะใส่บาตร สะโพกด้านซ้ายกระแทกพื้น ไม่สลบ ศีรษะไม่กระแทกพื้น ไม่มี บาดแผลตามตัว ปวดบริเวณสะโพกซ้ายมาก เดินลงน้าหนักไม่ได้ ขยับแล้วปวดมากขึ้น ยกขาซ้ายไม่ขึ้น กระดกข้อเท้าได้ ไม่มีอาการ ชาหรืออ่อนแรง
- 5. PRIMARY SURVEY • A : Able to speak, No hoarseness , no c-spine tenderness, full ROM • B : Normal chest expansion , clear and equal breath sound both lungs, Chest Compression Test negative • C : BP 2035/100 mmHg, PR 83 bpm, no active external bleeding. Tender at left groin area, no external wound, no swelling, left leg shortening with slightly external rotation • D : E4V5M6 , pupil 3 mm RTLBE • E : As shown on diagram
- 6. = Tender point • Left leg shortening • DP pulse 2+ • Cap. Refill < 2 sec • Motor of ankle dorsiflexion and plantar flexion = grade V
- 7. ADJUNCT TO PRIMARY SURVEY
- 8. SECONDARY SURVEY • A : Deny any food and drug allergy • M : • P : • L : 08.00 3/1/18 • E : Falling HT ไม่มาพบแพทย์ ไม่รับประทานยา 5+ yr
- 9. SECONDARY SURVEY • Head and Maxillofacial: • No external wound , no facial deformity, no ecchymosis • C spine and Neck: • no wound at neck , active moment and full ROM • Chest • Trachea in midline, tender at left middle chest, no abrasion wound, no subcutaneous emphysema, chest compression positive, clear and equal breath sound both lungs, normal resonance on percussion
- 10. • Abdomen and Pelvis • Soft, not tender abdomen, tender at left groin area • Perineum and Rectum • No ecchymosis • Musculoskeletal • Tender at left groin area, shortening of left extremity • Neurologic • GCS E4V5M6 • Pupil 3 mm RTLBE, full EOM, no facial palsy • Motor : grade V except left lower extremity due to pain
- 11. PROBLEM LIST • Closed Fracture of left neck of Femur. • High blood pressure in untreated HT patient BP 179/99 after receive 1 dose of Amlodipine(5)
- 13. • Blood supply to Femoral Head
- 15. ROLLING TEST
- 16. RADIOGRAPHIC REPORT CHECKLIST • AP pelvis and lateral hip should be viewed (pelvic fractures can mimic clinical features of hip fracture) • Trace Shenton’s line • Assess for symmetry, particularly prominent lesser trochanter (may indicate external rotation) • Bone trabeculae • Sclerosis at fracture plane
- 20. Recommendation from AAOS 2014
- 21. SUPPORTIVE TREATMENT • Pain Control • Underlying Disease : Control BP • Nutritional Support
- 22. POST OPERATIVE MANAGEMENT • Post operation Complication • Pain Control • Wound care • VTE Prevention • PT • Fall prevention • Osteoporosis Management
- 23. REFERENCE • 1. Rockwood C, Green D, Court-Brown C, Heckman J, McQueen M. Rockwood and Green's fractures in adults. Philadelphia (Pa): Wolters Kluwer Health; 2015. • 2. [Internet]. Aaos.org. 2018 [cited 9 January 2018]. Available from: http://www.aaos.org/education/anmeet/participants/icl_symp_handout_info_g uidelines.pdf • 3. Online CME 03/2011 [Internet]. Hkma.org. 2018 [cited 9 January 2018]. Available from: http://www.hkma.org/english/cme/onlinecme/cme201103main.htm • 4. Gaillard F. Femoral neck fracture | Radiology Reference Article | Radiopaedia.org [Internet]. Radiopaedia.org. 2018 [cited 9 January 2018]. Available from: https://radiopaedia.org/articles/femoral-neck-fracture • 5. Team M. Anvil Test | MediSavvy [Internet]. MediSavvy. 2018 [cited 9 January 2018]. Available from: https://medisavvy.com/anvil-test/ • 6. Femoral Neck Fractures - Trauma - Orthobullets.com [Internet]. Orthobullets.com. 2018 [cited 9 January 2018]. Available from: https://www.orthobullets.com/trauma/1037/femoral-neck-fractures
Editor's Notes
- ลืม film femoral
- iliopsoas and gravity will rotate the femur externally instead of rotating the hip internally
- major contributor is medial femoral circumflex (lateral epiphyseal artery) displacement of femoral neck fracture will disrupt the blood supply and cause an intracapsular hematoma (effect is controversial)
- Patient supine, examiner flexes patient’s leg straight to 30°. Examiner then applies gentle axis compression to the leg (compressing hip joint) Examiner finally strikes the patient’s heel. Interpretation Hip pain is a positive sign of this test, indicating possible hip pathology. If local femoral, tibial, fibular or calcaneal pain is elicited, consider a diagnosis of fracture, or strain/sprain in the region corresponding to the pain.
- The log roll is the single most specific test for hip pain. The examiner uses one hand and gently and repeatedly rolls the hip in external and internal rotation and looks for discomfort or hip pain. This test only moves the femoral head in relation to the acetabulum and the capsule, and is thus a sensitive test of the origin of hip pain.