Extern conference Ext.ปัญชลิตา 28 กย.61

1. Extern Conference
Ext.ปัญชลิตา วรกันต์กุล

2. History
• Patient Profile: ผู้ป่วยหญิงไทย อายุ 49ปี
• Chief Complaint: ปวดสะโพกซ้าย 5ชั่วโมง
• Present Illness:
– 5ชั่วโมง PTA ขับMCล้ม สะโพกซ้ายกระแทกพื้น จากนั้นปวดสะโพกซ้าย
เดินไม่ได้ ไม่มีศีรษะกระแทกพื้น ไม่สลบ จาเหตุการณ์ได้

3. Primary Survey
• A – can speak, not tender C-spine, full ROM
• B – clear, equal both lungs, CCT negative
• C – BP 125/80mmHg, PR90bpm, no active
bleeding
• D – E4V5M6, pupils 2mm RTLBE

4. Primary Survey
• E
– Lt hip: Tender and limit ROM due to pain, Abrasion
wound 5x5cm
– Lt leg: Shotening and external rotation,
motor gr.V, sensory intact
– Lt PTA, DPA 2+

5. Secondary Survey
• A – no drug allergy
• M – no current medication
• P – no U/D
• L – 5hr PTA
• E – ขับMCล้มเอง

6. Investigation: Film hip AP, Lateral

9. Diagnosis
• Closed fracture Lt neck of femur
Garden class IV, Pauwels type II

10. Femoral Neck Fracture

11. Introduction
• Epidemiology
– Common in eldery
– Women > Men
• Mechanism
– High energy in young patients
– Low energy falls in older patients
• Pathophisiology
– Femoral neck is intracapsular, bathed in synovial fluid
– Callus formation limited, which affects healing

12. Anatomy

13. Sign & Symptom
• Impacted fracture (nondisplaced)
– Slightly pain in the groin or pain referred along the medial
side of the thigh and knee
– No obvious clinical deformity
– Minor discomfort with active or passive ROM
– Pain with percussion over greater trochanter
• Displaced fracture
– Pain in the entire hip region
– Leg in external rotation and abduction with shortening
– Limit ROM

14. Investigation
• Film:
– Both hip AP
– Lateral cross-table
• CT: if doubtful

15. Garden Classification

16. Simplified Garden Classification
• Nondisplaced: Garden I and II
• Displaced: Garden III and IV

17. Pauwels Classification

18. Pauwels Classification
• Type I – Multiple screw
• Type II, III – Dynamic hip screw

19. Management
• Surgery if possible
– Conservative: bedridden, infection, DVT/PE
• Surgical choices:
– Fixation vs Arthroplasty

20. Femoral
neck Fx
Displaced
Age < 60
Undisplaced
Fixation in
all age
groups
Displaced
Age > 60

21. Displaced
Age < 60
-Age < 60 and
no risk for
osteoporosis
or
- Some risk but
age < 40
-Age 40-60 and
risk for
osteoporosis
-Age 40-60 and
alcohol abuse
Reduction and
fixation
Bipolar
hemiarthroplasty
THR probably
best option

22. Displaced
Age > 60
Independently
mobile,
no cognitive
impairment,
no comorbidities
Independently
mobile,
No/mild cognitive
impairment,
Limit to house or
short distance
Cognitive
impairment,
Poor function
Major
comorbidities
Total hip
arthroplasty
Unipolar
hemiarthroplasty
Bipolar
hemiarthroplasty

23. Complication
• Osteonecrosis
– 10-45%
– Increased risk with initial diaplacement
• Delay-union and nonunion

26. Thank you for your attention