Intertrochanteric fracture (2)
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Transcript of Intertrochanteric fracture (2)
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6th year medical cadet . Vasin Chantaraponpun
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Profile : ผู้ ป่วยหญิงไทย อาย ุ73 ปี u/d hypertension
อาชีพแมบ้่าน เชือ้ชาตไิทย สญัชาตไิทย ศาสนาพทุธ ภมิูลาํเนา อําเภอเมือง จงัหวดั
นครราชสีมา
Chief complaint : ปวดสะโพกซ้าย 6 ชัว่โมงก่อนมา รพ.
Present illness : 6ชัว่โมงก่อนมา รพ. ผู้ ป่วยล่ืนล้มบริเวณพืน้ห้องนํา้
สะโพกกระแทกพืน้ ไมมี่แผล ไมมี่ศรีษะกระแทก จําเหตกุารณ์ได้ มีอาการปวดมาก ลกุไม่
ขึน้ เดนิไมไ่ด้ รถ EMSนําสง่โรงพยาบาลมหาราช
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A - Can talk, C-spine no stepping, posterior neck not painB - Trachea in midline,equal breathe sound,not use of accessory muscleC - Alert,BP 127/86 mm.Hg,PR 90 bpm, Capillary refill < 2secD- E4V5M6 ,pupil 3mm RTBLEE- no external wound,no active bleeding, no stepping
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A - not allergyM - no medicationP - ไมเ่คยประสบอบุตัเิหตมุาก่อน,ไมมี่ประวตัิเป็นโรคร้ายแรง
L - Last meal 12.00 pm (3 hr.PTA)E - ล่ืนล้มสะโพกกระแทกพืน้กระเบือ้งท่ีบ้าน ไมมี่แผล ปวดมากลกุไมข่ึน้
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Vital sign : BT 36.7 C BP 127/86 mm.hg PR 90 bpm
Head & Maxillofacial : no external wound , no stepping , not tender
Cervical spine & neck : trachea in mid line , not tenderness along c-spine , no subcutaneous emphysema , no stridor
Chest : equal breathe sound,no adventitious sound
Abdomen : soft, not tender , no distention,no guarding
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Perineum : no external wound , PR >> no blood
Musculoskeletal : marked tender at left hip, no external wound, Anvil’s test +Rolling test +,No ecchymosisLimit ROM
Neurologic : E4VTM6 , pupil 3 mmRTLBEMotor grade V 4 extremitiesSensory grossly intact
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Admit On skin traction 2 kg. Operation for Gamma nail
Diagnosis
“Left intertrochanteric fracture of femur”
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6th year medical cadet . Vasin Chantaraponpun
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Fracture between greater trochanter and lesser trochanter in the intertrochanteric line
• Made of dense trabeculae bone
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- Most common in Ages > 70- Most common is extracapsular fracture- Mostly related with osteoporotic pateintMechanism :
elderly (90%)◦ low energy falls in osteoporotic patientsyoung (10%)◦ high energy trauma
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Patient usually complaint with can’t move after trauma
Pain at proximal thigh Progressive pain when flex hip and external rotate
lower extremity Shortened thigh Ecchymosis Swelling
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- Radiographs recommended views◦ AP pelvis◦ AP of hip, cross table lateral◦ full length femur radiographs
- CT or MRI
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Boyd and Griffin classification Evan’s classification AO classification
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Stable Unstable comminuted
Unstable reverse obilque
Intertrochanteric –subtrochanteric with two plane fracture
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Stable definition◦ intact posteromedial cortex
Clinical significance◦ will resist medial compressive loads once reduced
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Unstable definition◦ comminution of the posteromedial cortex
( Boyd and Griffin type 2)◦ fracture will collapse into varus and retroversion
when loaded◦ reverse obliquity pattern ( Boyd and Griffin type
3)◦ Displaced trochanteric fracture from
subtrochanteric
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Conservative treatment Operative
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Non- weightbearing with early out of bed to chair
Indication : - Stable type- non ambulatory patient- patient with high risk of
perioperative mortality
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Sliding hip compression screw Cephalomedullary nail Arthroplasty
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Stable intertrochanteric fractures equal outcomes when compared
to Cephalomedullary nailfor stable fracture patterns
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• stable fracture patterns
• unstable fracture patterns
• reverse obliquity fractures
• Failure when treated by compression screw
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severely comminuted fractures
preexisting symptomatic degenerative arthritis
osteoporotic bone that is unlikely to hold internal fixation
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Malunion :mostly from conservative treatment
Nonuinon : found < 2% because of extracapsular fracture
Loss of fixation : most common found in unstable type can be proved by refixation or arthroplasty
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ตาํรา Orthopaedics for medical student, วิทยาลยัแพทยศาสตร์พระมงกฎุเกล้า
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