Extern Noon Conferenceณัฐพล ภาณุพนิธุ11/11/59

Case ชายไทย อายุ 15 ปี• นักเรยีนชัน้มธัยมศึกษาชัน้ปีท่ี 3 โรงเรยีนนิคมพมิาย

ศึกษา• ภมูลิำาเนา อำาเภอพมิาย จงัหวดันครราชสมีา• นำาสง่ emergency department โดย ambulance จากโรงพยาบาลพมิาย (21:00)• ประวติั MC ล้ม 30 นาทีก่อนมาโรงพยาบาล (17:00)• จำาเหตกุารณ์ตอนเกิดเหตไุมไ่ด้ ต่ืนขึน้มามบีาดแผลถลอก

ตามตัว สะโพกขวาผิดรูป ปวด และขยบัไมไ่ด้

Acute hospital management at ERAdvanced trauma life support protocol•Airway maintenance with cervical spine control•Breathing and ventilation•Circulation with hemorrhagic control•Disability evaluation•Exposure and environmental controlในเบื้องต้นต้อง R/O head and c-spine injury?, shock?, severe skeletal and soft tissue injury? เพราะม ีmechanism ท่ีรุนแรงพจิารณาสง่ films C-spine (lateral), CXR, pelvis (AP), ทำา FAST

Primary survey and adjuncts to primary survey•Airway maintenance with cervical spine control –

รูตั้วดี พูดคยุได้ ไมเ่จบ็บรเิวณใบหน้า ศีรษะ และคอ•Breathing and ventilation – RR 18/min, regular, good air entry, clear, equal breath sounds, compression tests negative•Circulation with hemorrhagic control – BP 110/70 mmHg, PR 86/min full, regular, symmetrical•Disability evaluation – GCS = 15, pupils 3 mm RTLBE•Exposure and environmental control – no external bleeding, no hypothermia

Adjuncts – NG ได้ clotted blood, FAST positive (hepatorenal), film pelvis AP ม ีdeformity of the right hip

Secondary survey: AMPLE•Allergy – none•Medication – none•Past medical history – none•Last meal – 11:30•Events – as described

Physical examination• GA : A young man, good consciousness, well co-operative, no dyspnea• Vital signs: Temp 36.8 C, BP 110/70 mmHg, PR 86/min, RR 16/min• HEENT : no pale conjunctivae, anicteric sclera• CVS : full regular pulses all extremities, normal S1 S2, no murmur• Respiratory : No dyspnea, normal breath sound, no adventitious sound• GI : Soft, mild tender at RUQ and epigastrium, no distension, normoactive bowel sound• MSK: Back – not tender, no stepping, no wound

Affected parts – next slide

Physical examination: right hip, thigh and leg

• Fixed position of the right hip1. External rotation2. Abduction3. Flexion

• Fullness and tender at right groin

• Few lacerated wounds on the right thigh and leg

• Unable to move the right hip, limited ROM of the right knee due to pain

• No foot drop, EHL power grade 5

• Pulses: right PA 2+, PTA 2+, DPA 2+

Film X-ray of Pelvis (AP view)• The lesser

trochanter is more visible due to external rotation

• The hip is abducted• The femur head is

usually inferior to the acetabulum

• Shenton's line is also broken.

• No fracture seen

Pertinent findings•Mild tenderness at RUQ and epigastrium•Deformity of the right hip with painful sensation and limited ROMProblem list•Blunt abdominal trauma (hemodynamic stable)•Anterior dislocation of the right hip

Management at ER (trauma + ortho)•Admit•Monitor V/S, I/O•NPO•5% DN/2 (1000) IV drip rate 80 ml/h•CBC, anti-HIV•Films: skull AP lateral, chest, pelvis AP, film right leg AP including knee•Retained NG and lavage with NSS 500 ml•FAST, CT whole abdomen•Pethidine (1 mg/kg) 45 mg IV prn q6h•Cefazolin 1 g IV to OR•Set OR emergency for close reduction of the right hip under GA

CT whole abdomen•Small laceration at hepatic segment 6, suspecting grade II liver injury•Small left pneumothorax•Right anterior hip dislocation

Closed reduction under GA• Traction and

counter traction• Adduction• Internal rotation

Results and further management• Successful reduction

with stable and intact femoral bone and pelvis

• No disruption of Shenton’s line

• No leg length discrepancy

• Intact neuro-vascular status

• Partial weight bearing with axillary clutch, ROM exercise, strengthening exercise

• Follow-up for 2 years for late complication

Hip dislocationIndication for surgery•Hip dislocation with femoral neck or acetabular fracture• Incarcerated fragment in the hip joint• Irreducible reduction• Incongruent reduction (does not fit properly)•Unstable hip after reduction

Anatomy of hip jointBall-and-socket joint surrounded by ligaments

Hip dislocationSummary•Typically caused by high-energy trauma, frequently in young patients•Types of dislocations - Anterior dislocation - Central acetabular fracture dislocations - Posterior hip dislocation usually with

posterior acetabular wall fracture

Posterior hip dislocation (90%)•A posterior dislocation leaves the lower leg in a fixed position, with the knee and foot rotated internally

Hip dislocationAssociated injuries•Multiple trauma, sometimes life threatening• Ipsilateral femoral neck, femoral shaft fracture• Ipsilateral patella fracture• Ipsilateral knee injuries (cruciate, collateral ligaments and periarticular fracture)• Sciatic nerve

Hip dislocationManagement•True orthopedic emergency•Reduction within 6 hours – preventing avascular necrosis of the femoral head•Reduction under general anesthesia or spinal anesthesia•Allis maneuver for hip dislocation•Test for stability of the hip after reduction•Re-evaluate associated fracture of acetabulum and femoral head•Re-evaluate vascular status and sciatic nerve functions