Extern conference Ext.นันทิชา 30 พ.ค. 61

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