noon conf. [ext.worawan]

EXTERN NOON CONFERENCE

ext. วรวนท เจยตระกลโรงพยาบาลรามาธบด

CHIEF COMPLAINT

ผปวยชายไทย อาย 35 ป ขาผดรป 4 ชวโมงกอนมาโรงพยาบาล

PRIMARY SURVEY A : Can speak, c-spine not tender, full ROM B : Clear breath sound equal both lungs, trachea in midline, CCT negative

C : BP 103/69mmHg, Pulse 100 bpm, capillary refill time < 2 sec, no active bleeding

D : E4V5M6, pupils 3 mm RTLBE E : No external wound

SECONDARY SURVEY A : No history of food and drug allergy M : No current medications P : HBV carrier L : 21:00 (8.5 hr PTA) E : 4 hr PTA ผปวยขบรถกระบะลงคนำ(าขางทาง เขาท(งสองขางชนคอนโซล

หนารถ เขาท(งสองขางตดอยใตคอนโซล หลงพยายามเอาขาออกจาก คอนโซล ขาขวาผดรป ปวดบรเวณสะโพกขวา ขยบสะโพกขวาไมได เดนไมได

มประวตดมสรา ปฎเสธประวตศรษะกระแทก จำาเหตการณได ไมสลบ ไมม ปวดศรษะ ปฎเสธอก/ทองกระแทก

HEAD TO TOE EXAMINATION GA : Good consciousness, not pale, no jaundice VITAL SIGN : BT 37C, BP 103/69 mmHg, Pulse 100 mmHg, RR 16 times/min

HEENT : No pale conjunctiva, anicteric sclera HEART : Full regular pulse, normal s1 s2 no murmur LUNGS : Clear equal both lungs, no adventitious sound ABDOMEN : No distension, normoactive bowel sound, soft, not tender

EXT. : as picture

Inspection : Rt. Hip – flexion & adduction & internal rotation

Abrasion wound at Lt. knee Palpitation : Tender at Rt. Hip Range of motion : limit ROM of Rt. Hip Neurovascular : Normal sensation, can dorsiflexion and plantar flexion DPA 2+

FILM BOTH HIP AP

DIAGNOSIS # Posterior Right hip dislocation # Mild head injury (Moderate risk)

(POSTERIOR) HIP DISLOCATION

OUTLINE Epidemiology Anatomy Classification Presentation Imaging Management Complications

EPIDEMIOLOGY RARE ! Most commonly dislocated joint of the lower extremity, with incidence of 5.2% Male : Female = 4 : 1 Mechanism is usually young patients with high energy trauma

ANATOMY

BLOOD SUPPLY

EMERGENCY CONDITION !!

Multiple traumaAvascular necrosis

TYPE Simple : pure dislocation without associated fracture

Complex : dislocation associated with fracture of acetabulum or proximal femur

ANATOMIC CLASSIFICATION Posterior dislocation (90%) occur with axial load on femur, typically with hip flexed and adducted axial load through flexed knee (dashboard injury)

Anterior dislocation (10%) occurs with the hip in abduction and external rotation

Central dislocation caused by a lateral force against an adducted femur  always a fracture-dislocation

PRESENTATION Symptoms : acute pain, deformity, inability to move the hip joint, inability to bear weight

Physical exam : HIP >>> flexion, adduction, and internal rotation examine knee for associated injury or instability neurovascular exam (10-20% sciatic nerve injury)

SCIATIC NERVE Common peroneal (fibular) nerve Sensation : lateral side of the lower leg and upper surface of the foot

Motor : dosiflexion

Tibial nerve Sensation : sole of the foot Motor : plantar flexion

IMAGING Radiographso Shenton's line brokeno femoral head smaller than contralateral sideo lesser trochanter shadow reveals internally rotated limb as compared to contralateral side

IMAGING CTpost reduction CT must be performed for all traumatic hip dislocations to look for femoral head fractures, loose bodies, acetabular fractures

MANAGEMENTNon-operative : Emergent closed reduction within 6 hr

Allis maneuver Stimson maneuver Bigelow maneuver

Operative

ALLIS MANEUVER

STIMSON MANEUVER

contraindicated in the setting of thoracoabdominal trauma or a difficult airway.

BIGELOW MANEUVER

OPERATIVE Indications• Irreducible dislocation (approximately 10% of all dislocations)• Persistent instability of the joint following reduction (eg, fracture-dislocation of the posterior acetabulum)• Fracture of the femoral head or shaft• Neurovascular deficits that occur after closed reduction

COMPLICATIONS Post-traumatic arthritis  up to 20% for simple dislocation, markedly increased for complex dislocation If an associated acetabular fracture is present, the incidence of traumatic arthritis is as high as 80%.

Femoral head osteonecrosis 5-40% incidence Increased risk with increased time to reduction

Sciatic nerve injury 8-20% incidence associated with longer time to reduction

Recurrent dislocations less than 2% Risk factors for recurrent dislocation are large capsular defects, intra-articular fragments, or a prosthetic hip.

MANAGEMENT IN THIS PATIENT CT Brain non-contrast Set OR for close reduction under GA Test stability 30, 60, 90 Repeat film after reduction Repeat neurovascular examination On skin traction 2 kg.

FILM S/P CLOSED REDUCTION

REFERENCES www.orthobullets.com emedicine.medscape.com Hip fracture -dislocation and fracture femur, นพ. นรเทพ กลโชต, โรงพยาบาลรามาธบด

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