OrthopaedicTeleconference

By Ext. Anat Chenae RAMD 5402176

Patient Profile

Chief Complaint

• A : Patent Airways , no C-spine tenderness

• B : No dyspnea , no open wound on chest wall

Trachea in midline, ribs - not tender, no stepping, Normal equal breath sound, No adventitious sound both lungs

Primary Survey

• C : BP 160/ 80 mmHg, PR 90 bpm

Full regular pulses, Capillary refill < 2 sec, No external active bleeding, Pelvic compression test – negative

• D : E4V5M6 , pupil 3 mm RTLBE,

• E : Swelling and tender at Left greater trochanter, not seen external wound

Primary Survey

Secondary Survey

• Allergy : none

• Medication : Amlodipine po pc

• Past Illness : Hypertension

• Last meal : 19.00

• Event :

Secondary SurveyHead to toe examination

• GA : An elderly Thai woman, good consciousness ,not pale, no jaundice

• HEENT : Not pale conjunctivae, anicteric sclera

• CVS : Full symmetrical regular pulse,no carotid bruit, normal S1 S2, no murmur

• Respiratory : No dyspnea, trachea in midline normal equal breath sound both lungs no adventitious sound

Secondary Survey• GI : No distention, normoactive bowel sound

,soft, not tender, no guarding/rebound tenderness

• Extremities

- Inspection : Swelling at left femur, not seen External wound

- Palpation : Tenderness at left greater trochanter

- Limit ROM of Left hip due to pain (flexion, extension, abduction, adduction, rotation)

Secondary Survey

- Special test : Anvil and Rolling positive at Left leg

- Neurovascular : Full Left Dorsalis pedis a., Posterior tibiala., Popliteal a.

Capillary refill < 2 secMotor power grade V all except at left hip can not evaluate due to pain

Film pelvis AP

Film Lt hiplateral

Diagnosis

Definition Epidemiology Mechanism Clinical Presentation Physical Examination Imaging Classification Management

Extracapsular fracture occur in the region between the greater and the lesser trochanters of the femur; occasionally extending to the subtrochanteric region

Deforming muscle forces will usually produce shortening, external rotation and varusposition at the fracture

Definition

FACTORS CONTRIBUTORY TO THE DEVELOPMENT OF AN IT FRACTURE

Advancing age

Increased number of comorbidities

Increased dependency in activities of daily living

History of other osteoporosis-related (fragility) fractures

EPIDEMIOLOGY

• Varies from country to country.

• United States – 150,000 fractures annually with an annual incidence of 63 and 34 per 100,000 for elderly males and females respectively

In younger individuals are usually the result of a high-energy injury, such as a motor vehicle accident (MVA) or fall from a height

In the elderly, it results from a simple fall (trivial trauma). The tendency to fall increases with patient age and is exacerbated by several factors including poor vision decreased muscle power labile blood pressure decreased reflexes vascular disease

Mechanism

Pain Marked shortening of lower limb Patient cannot lift his/her leg

Complete External Rotation Deformity Swelling, ecchymoses and Tenderness over the Greater

Trochanter

Clinical Presentation

Physical Examination Tenderness, ecchymosis at greater trochanter

Shortened lower extremity

Externally rotated lower extremity

Diagnostic Imaging

• Radiographs

- AP pelvis

- AP of hip, cross table lateral

- full length femur radiographs

• CT or MRI

useful if radiographs are negative but physical exam consistent with fracture

Management

Nonoperative – “skin traction” 4-6 weeks

Indications

- non-ambulatory patients

- patients at high risk for Surgery

Outcomes

- high rates of infection eg.pneumonia, urinary tract infections, pressure sore, and DVT

Operative

ORIF

Indications

-stable fracture patterns

-unstable fracture patterns

-reverse obliquity fractures

-subtrochanteric extension

Complication

1. Nonunion (<2%)2. Malunion - varus and rotational deformities are common

3. Loss of fixation

References

Hip fracture-dislocation and fracture femur

http://orthoinfo.aaos.org/topic.cfm?topic=A00392

http://www.orthobullets.com/trauma/1038/intertrochanteric-fractures