Post on 18-Jan-2017
Orthopedics Noon conference
นพท. อรรณพ กตตถาวรวทยาลยแพทยศาสตรพระมงกฎเกลา
History takingCase ผปวยหญงไทยค อาย 67 ป เชอชาต ไทย
สญชาตไทย ศาสนา พทธ ภมลำาเนา: จงหวด นครราชสมา อาชพ: ทำานา สทธการรกษา:หลกประกน
สขภาพถวนหนา
รบเขารกษา ในโรงพยาบาล วนท 15 พฤศจกายน 2559 เนองดวย (chief complaint): ไมสามารถเดนได 4hrs.PTA
Primary surveyA : A Thai woman able to talk, No stridor, Not
tender at C-spine, Active neck flexion
B : RR 20/min, no dyspnea , normal chest expansion ,trachea in midline, normal breath sound and equal both lungs, no ribs stepping and
tenderness, no open wound on chest wall
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Primary survey C : BP 140/73 mmHg, PR 66 bpm, Pulse full and
regular, Capillary refill <2 sec. no external active bleeding, pelvic compression test : negative
D : E4V5M6, pupils 3 mm RTLBE.
E : On splint at left leg, no open wound and active bleeding, no ecchymosis, Left leg was shortening , slightly external rotation and abduction of left leg, mild tenderness on left hip PR : not done
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Adjunct Primary Survey
• Fracture immobilizaton
Monitor :
o Monitor vital signs
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Secondary survey• A : No food/drug allergy
• M : Amlodipine(5) 2x1oral pc in the morning
• P : Hypertension
• L : Last meal at 06.00 am.
• E : 4 ชม.กอนมารพ. ขณะเกบผายางตากขาว ผปวย เดนถอยหลงสะดดและลมลง ศรษะไมกระแทก
Secondary survey• Event: 4hrs. PTA
-ขณะผปวยเกบผายางทใชตากขาวเปลอกหนาบานผปวยเดนถอยหลงจากนน
สะดดกอนอฐแลวลมลง สวนของเอวและสะโพก ขางขวากระแทรกพน ศรษะไมกระแทกพน ไมสลบ
จำาเหตการณได หลงจากนนมอาการเจบทบรเวณสะโพกขางซาย
-ผปวยสามารถพยงตวเองลกขน เดนได แตเดนในลกษณะเดนกะเผลก
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• Event: 4hrs. PTA
- ผปวยพยายามทจะเดนเขาหองนำา จากนนลน บรเวณหองนำา แตไมลมเนองจากมญาตมาชวยพยง
ไดทน หลงจากทผปวยลนผปวยรสกเสยวบรเวณตน ขาซาย ลงนำาหนกไมได เดนเองไมได และปวดบรเวณ
สะโพกซายมากขน- ปฎเสธประวตอบตเหต ชนหรอกระแทกมา
กอนหนา , ประจำาเดอนหมดตงแต อาย40 ป
Secondary survey
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Physical examination• Vital signs: Temp =37.1°C RR=20/min
BP=140/73mmHg PR=66/min
GA: An old Thai woman ,good consciousness, well cooperate, no pallor ,no jaundice
HEENT: no pale conjunctivae, anicteric sclerae
CVS: full and regular pulse, normal s1,s2 no murmur
Lungs: normal breath sound and no adventitious sound of both lungs
• Abdomen : no distension , normoactive bowel sound, no tenderness , no guarding
• Extremities : Left leg
-Inspection = no swelling, no ecchymosis , Left leg was shortening slightly external rotation and abduction of left leg
- Palpation = pain with percussion over greater trochanter
- Limit range of motion due to pain at left leg
- Anvil and Rolling test were positive at Left leg
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• Neurovascular :
o Full 2+ at Left femoral a. , Left Popliteal a. , Left posterior tibial a. and Left dorsalis pedis a.
o Normal capillary refill < 2sec
o Motor power of Left plantar flexion and dorsiflexion grade V
Pertinent findingsHistory taking
- Fall down
- Antalgic gait
- Unable to stand
- Inability to walk
- Pain in the entire Left hip
- Menopause
- No history of previous trauma
Physical examination
- Left leg was shortening - Slightly external rotation and abduction of left leg
- Pain with percussion over greater trochanter area
- Limit range of motion due to pain
- Anvil and Rolling test were positive at Left leg
- No ecchymosis
- No swelling
Shenton’s line
Film :Pelvis AP
Film :Hip AP
Film : Hip lateral
Film : Lt femur lateral
Diagnosis• Close fracture total displacement of Left femoral
neck
• Garden Classification : type IV
Fracture of neck femur
• Epidemiology• Pertinent anatomy• Pathophysiology• Mechanism of injury• Presentation• Prognosis• Garden Classification• Imaging• Treatment
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Epidemiology• increasingly common due to aging population
• women > men
• whites > blacks
• United states has highest incidence of hip fx rates worldwide
• most expensive fracture to treat on per-person basis
Pertinent anatomy• Femoral neck fractures are intracapsular
• The tenuous blood supply to the femoral neck increases the risk of complications, such as avascular necrosis
• Blood supply : major contributor is medial femoral circumflex (lateral epiphyseal artery)some contribution to anterior and inferior head from lateral
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Intracapsular versus extracapsular hip fractures
Pathophysiology• Healing potential
o femoral neck is intracapsular, bathed in synovial fluid
o lacks periosteal layero callus formation limited, which affects healing
Mechanism of injury● Femoral neck fractures tend to occur in elderly patients who fall
-A fall directly onto the lateral hip
-A twisting mechanism in which the patient's foot is planted and the body rotates
-A sudden spontaneous completion of a fatigue (or insufficiency) fracture, which then causes a fall
Mechanism of injury● In younger individuals
-Femoral neck fractures generally occur as a result of major trauma,
such as a motor vehicle collision or a fall from a height.
- Associated injuries femoral shaft fractures6-9% associated with femoral neck fractures
PresentationSymptoms
● impacted and stress fractures-slight pain in the groin or pain referred along the
medial side of the thigh and knee
●displaced fractures-pain in the entire hip region
Physical exam
● impacted and stress fractures-no obvious clinical deformity-minor discomfort with active or passive hip range of
motion, muscle spasms at extremes of motion-pain with percussion over greater trochanter
● displaced fractures- leg in external rotation and abduction, with shortening
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Prognosis• mortality
o ~25-30% at one year (higher than vertebral compression fractures)
• predictors of mortalityo pre-injury mobility is the most significant
determinant for post-operative survival o in patients with chronic renal failure, rates of
mortality at 2 years postoperatively, are close to 45%
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Garden ClassificationType I : Incomplete, ie. valgus impacted
Type II :Complete fx. Nondisplaced
Type III :Complete, partially displaced
Type IV : Complete, fully displaced
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Imaging• Radiographs
• Garden classification is based on AP pelvis• CT
o helpful in determining displacement and degree of comminution in some patients
• MRI , Bone scano helpful to rule out occult fracture
• Duplex Scanning• rule out DVT if delayed presentation to
hospital after hip fracture
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Treatment• Non-operative
►observation aloneo indications• may be considered in some patients who are
non-ambulators, have minimal pain, and who are at high risk for surgical intervention
• Operative ► ORIF
-Displaced fractures in young ORIF indicated for most pts <65 years of
age
Treatment• Operative ► Cannulated screw fixation
-nondisplaced transcervical fx-Garden I and II fracture patterns in the
physiologically elderly-displaced transcervical fx in young patient
Treatment• Operative
►total hip arthoplasty -older active patients >65 years of age-patients with preexisting hip osteoarthritis-Arthroplasty for Garden III and IV in patient < 85 years
Fracture neck of femur
Non-displaceme
nt
Conservative Multiple screws
Displacement
Physiologically <60-65 years
Closed reduction under x-ray
Reduction possible
Multiple screw
Reduction not
possible
Open reduction
screw fixation
Physiologically >60-65 years
Healthy ,no functional limitation or hip osteoarthritis
THA Hemi:active community
walker
Bipolar
Unipolar
yes No
yes
No
Supportive treatment• Pain control
Morphine 3 mg v prn q 6 hr
• On skin traction at Lt leg with 2 kg
• Plasil 10 mg v prn q 6 hr
• Underlying disease Amlodipine(5) 2x1oral pc in the morning
• Nutritional support low salt diet
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Complication• Osteonecrosis incidence of 10-45%
• Nonunion incidence of 5 to 30%increased incidence in displaced fractureso no correlation between age, gender, and rate
of nonunion
• Dislocation higher rate of dislocation with THA (~ 10%)
References• http://www.orthobullets.com/trauma/1037/
femoral-neck-fractures• www.uptodate.com/Hip fractures in adults ;
Katherine Walker Foster, MD: Oct 31, 2016• ธรชย อภวรรธกกล.Orthopaedic Trauma. พมพครงท
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