Ortho Ext. ธมลวรรณ 7 กพ.61

1. Extern Conference
Extern Thamolwan Padthaisong

2. Case : ผูปวยหญิงอายุ 74 ป U/D HT, DLP
HN 545148
•Chief complaint : ปวดตนขาซาย 5 ชั่วโมง PTA
•Present illness : 5 ชั่วโมง PTA นั่งครอมรถ MC เอื้อมมือกําลัง
ปดประตูบานแตเสียหลักรถลมทับขาขางซาย ปวดบริเวณตนขา
ซายมากราวไปตนขา ไมสามารถยืนเดินได ไมมีขาชา ไมมี
ศีรษะกระแทกพื้นหรือหมดสติ

3. Primary survey
•A : Patent airway, no stridor, no posterior cervical tenderness
•B : Equal chest expansion, trachea in midline, equal breath sound
both lungs
•C : BP 126/84 mmHg , PR 80 bpm, no external bleeding, no pelvic
tenderness or ecchymosis, abdominal soft not tender
•D : E4V5M6, pupils 3 mm RTLBE
•E : External rotation at left leg , no swelling and ecchymosis
PR – normal sphincter tone, yellow feces

4. Secondary survey
•A : No history of allergy
•M : Current medication : ASA(81) 1x1, HCTZ(25)1x1,simvas(40)0.5xhs,
enaril(5)1x2
•P : Underlying disease ; HT, DLP
•L : Last meal 14.00
•E : As above

5. Head to Toe Evaluation
•Vital signs : BT36.5 c, PR 80 bpm, RR 14/min, BP 126/84 mmHg
•GA : Good consciousness, not pale
•HEENT : no pale conjunctivae, anicteric sclerae, no subconjunctival
hemorrhage, no evidence of head trauma, no contusion
•Lungs : Equal chest expansion, equal breath sound, no accessory
muscle use, both lungs clear
•CVS : JVP not engorged, pulse full and regular, capillary refill < 2 sec,
normal S1S2, no murmur

6. Head to Toe Evaluation
•Abdomen : No distention, soft, not tender, normoactive bowel sound,
no rigidity, no guarding, no rebound
•Extremities : External rotation at left leg, anvil and rolling test
positive, capillary refill < 2 sec, DPA 2+, PTA 2+
•Neuro : Good consciousness, well cooperated, good orientation to
time/place/person
•Motor : Grade V all extremities except left leg due to pain
•Sensory : Normal sensation to pain, temperature and fine touch

8. Investigation : Film Xray
•Both hip AP
•Left hip AP ,Lateral

10. Dx : Closed fracture left femoral neck

11. Anvil test Rolling test

12. Femoral neck fracture
Shenton’s line

14. Garden classification

15. Stage I : incomplete fracture of the neck

16. Stage II : complete without displacement

17. Stage III : complete with partial displacement

18. Stage IV : this is a complete femoral neck fracture with full
displacement

19. Treatment
Goal
•Minimize patient discomfort
•Restore hip function
•Allow rapid mobilization

20. Treatment
Nondisplaced or garden
type 1&2
•Non-operative treatment : bed
rest , traction
•Internal fixation
Displaced or garden type 3&4
•Age < 65 : internal fixation
•Age > 65 : arthroplasty

21. Complications
•Thromboembolism
•Avascular necrosis
•Nonunion