Ext.สุขุมาล 17 ธ.ค. 61

1. EXTERN CONFERENCE
EXTERN SUKHUMARN CHARTDUMDEE

2. PATIENT PROFILE
• ผู้ป่วยเด็กชายอายุ 14 ปี
• ภูมิลำเนาอำเภอ ขามทะเลสอ จังหวัด นครราชสีมา

3. CHEIF COMPLAINT
• ปวดสะโพกซ้าย 3 hr PTA

4. PRESENT ILLNESS
• 3 hr PTA รถเก๋งชนท้าย MC สะโพกซ้ายกระแทกพื้น มีสะโพกซ้าย
ผิดรูป เหยียดขาซ้ายไม่ได้ อยู่ในท่างอ เจ็บสะโพกซ้ายมาก เดินไม่
ได้ ไม่มีบาดแผล ไม่มีศีรษะกระแทก ไม่มีสลบ จำเหตุการณ์ได้
ไปรพช. และrefer มารพ. มหาราชนครราชสีมา

5. PRIMARY SURVEY
• A : can talk, no C-spine tenderness
• B : equal breath sound both lungs, CCT neg.
• C : BP 135/80 mmHg, PR 100 bpm
• D : E4V5M6, pupils 2 mm RTLBE
• E : No other wound

6. SECONDARY SURVEY
• AMPLE
• A: no food or drug allergy
• M: no current medication
• P: no underlying disease
• L: last meal 12.00 น.
• E:รถเก๋งชนท้าย MC สะโพกซ้ายกระแทกพื้น

7. • Head To Toe Evaluation
Heart : normal S1S2, no murmur
Lungs : equal breath sound both lungs
Abdomen : soft, not tender
Extremities : left hip flexion, internal rotate & adduction,
limit ROM due to pain, pinprick sensation intact, right DPA 2+
Neurological : E4V5M6, pupils 2 mm RTLBE
SECONDARY SURVEY

8. INVESTIGATION

9. Both hip AP Left hip lateral
Left knee
AP

10. Lt knee
lateral
Lt knee AP

11. DIAGNOSIS
• Posterior left hip dislocation

12. MANAGEMENT
• AT ER
-control pain
-Set OR for closed reduction under GA with skeletal
traction

13. POST OPERATION

14. HIP
DISLOCATION

15. INTRODUCTION
• Epidemiology
- rare, but high incidence of associated injuries
-mechanism is usually young patients with high energy trauma
• Hip joint inherently stable due to
- bony anatomy
- soft tissue constraints including
-labrum
- capsule
- ligamentum teres

16. CLASSIFICATION
• Simple vs Complex
- simple : pure dislocation without associated fracture
- complex : dislocation associated with fracture of
acetabulum or proximal femur

17. • POSTERIOR dislocation (90%)
- occur with axial load on femur, typically with hip
-axial load through flexed knee (dashboard injury)
• increasing flexion ,adduction and internal rotation
favors simple dislocation
• associated with
-osteonecrosis
-posterior wall acetabular fracture
-femoral head fractures
-sciatic nerve injuries
-ipsilateral knee injuries (up to 25%)
CLASSIFICATION(ANATOMICAL)

18. • ANTERIOR dislocation
- associated with femoral head impaction or
chondral injury
- occurs with the hip in abduction and external
rotation
• inferior ("obturator") vs. superior ("pubic")
1.hip extension results in a superior (pubic)
dislocation
-Clinically hip appears in extension and
external rotation
2.flexion results in inferior (obturator)
dislocation
-Clinically hip appears in flexion,
abduction, and external rotation
CLASSIFICATION(ANATOMICAL)

19. PRESENTATION
• Symptoms
- acute pain, inability to bear weight, deformity
• Physical exam
- ATLS : 95% of dislocations with associated injuries
- posterior dislocation (90%)
most common hip and leg in slight flexion, adduction, and internal
rotation detailed neurovascular exam (10-20% sciatic nerve injury) examine
knee for associated injury or instability
- anterior dislocation
hip and leg in flexion, abduction, and external rotation

20. IMAGING
• Radiographs
• recommended views
-AP
-cross-table lateral
used to differentiate between anterior vs
posterior dislocation
-obtain AP, inlet/outlet, judet views (after reduction)

21. IMAGING
• findings
-loss of congruence of femoral
head with acetabulum
-disruption of shenton's line (arc
along inferior femoral neck +
superior obturator foramen)

22. IMAGING
• Anterior dislocation
- femoral head appears larger than
contralateral femoral head
- femoral head is medial or inferior to
acetabulum
• Posterior dislocation
- femoral head appears smaller than
contralateral femoral head
- head superimposes roof of acetabulum
- decreased visualization of lesser
trochanter due to internal rotation of femur

23. TREATMENT
• Non-operative
-emergency closed reduction within 6 hours
indications
-acute anterior and posterior dislocations
contraindications
-ipsilateral displaced or non-displaced femoral

24. • ALLIS MANEUVER
(adequate sedation and
muscular relaxation)
• Test stability
Flex 60-90 degree
>กดเบาๆที่เข่า
• Skin traction 2-4 kg+film
x-ray
TREATMENT

25. • Operative
1.open reduction and/or removal of incarcerated fragments
indications
-irreducible dislocation
-radiographic evidence of incarcerated fragment
-delayed presentation
-non-concentric reduction
2.ORIF
indications
-associated fractures of acetabulum, femoral head/neck
TREATMENT

26. COMPLICATION
• Post-traumatic arthritis
-up to 20% for simple dislocation, markedly increased for complex dislocation
• Femoral head osteonecrosis
-5-40% incidence
-Increased risk with increased time to reduction
• Sciatic nerve injury
-8-20% incidence
-associated with longer time to reduction
• Recurrent dislocations
-less than 2%

27. “THANK YOU
FOR YOUR ATTENTION”