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 45 year old lady slips and falls on the ground. She is unable to get up and walk. The X Ray reveals a fracture of the femur at the lesser trochanter.

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Presentation on theme: " 45 year old lady slips and falls on the ground. She is unable to get up and walk. The X Ray reveals a fracture of the femur at the lesser trochanter."— Presentation transcript:

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2  45 year old lady slips and falls on the ground. She is unable to get up and walk. The X Ray reveals a fracture of the femur at the lesser trochanter.

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4  Two types  Extracapsular  Intracapsular  Extra capsular  Trochanteric  Subtrochanteric

5  Trochanteric (Evan’s classification)  Stable # configuration – Type A & B  Unstable # configuration – Type C & D  Type C – lateral cortex is intact  Type D – lateral cortex is violated  Type E – Reverse obliquity Fractures parallel to neck axis &traverse lat. cortex

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7  Subtrochanteric  Three types- Simple, Wedge, Complex All unstable due to relatively small contact area

8  Intra capsular  Classification (Low energy)  Fracture site- subcapitus, transcervical, basicervical  Inclination of the # -  Pauwel’s classification  Type I – 30 degree  Type II – 50  Type III – 70

9  Relation of # fragment  Garden classification  Type I – incomplete & impacted  Type II – Complete & undisplaced  Type III – Complete & partially displaced (intact post.retinacular ligament)  Type IV – completely displaced (disruption of reti.vessels)

10  Classification (High Enegy)  Type I - undisplaced neck #  Type II – simple displaced neck #  Type III – Comminuted displaced neck #  Type IV – FON + # of acetabulum or shaft of the femur  Type V – Neck # that occur or recognized during antegrade nailing of shaft

11  Safe place  Reassure the person  Have the victim lie flat and rest.  Ask for help  CPR  If there is a wound remove the clothes  If there is bleeding apply direct pressure to the wound to stop the bleeding.  Cover the wounded area with a clean cloth or dressing.  Continue to apply pressure as long as the wound bleeds. Add new dressings over existing ones.

12  Immobilize the injured area. A splint is a good way to immobilize the affected area, reduce pain and prevent shock.  Effective splints can be made. The general rule is to splint a joint above and below the fracture.  Or, lightly tape or tie an injured leg to the uninjured one, putting padding between the legs, if possible.

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17  Check the pulse in the limb with the splint. If you cannot find it, the splint is too tight and must be loosened at once. Check for swelling, numbness, tingling or a blue tinge to the skin. Any of these signs indicate the splint is too tight and must be loosened right away to prevent permanent injury  Keep her fasting  Inform relatives  Move to hospital

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19  Prevention  Pre-hospital care  Hospital care  Rehabilitation “Manage the patient, Not the fracture”

20  A = Airway  B = Breathing  C = Circulation  D = Disability of CNS  E = Exposure of the patient  F = Foley catheter

21  At risk in all unconscious patients.

22  Blood loss is greater than the NOF fracture and trochanteric fracture. Large volume of blood can accumulate in the thigh.  Skin: cold, pale,sweating  Pulse: rate, volume, rhythm  Blood Pressure  JVP Adequate fluid resuscitation.

23  Head injury  Examination: Level of consciousness External wounds Pupils- dilated, unequal  CT scan of the brain

24  Damage to cervical spine  Suspected in all unconscious and head injured patients.  In line bimanual immobilization  Semi rigid collar  X-ray cervical spine

25 Exposure : Foley catheter : Analgesics: Antibiotics

26 Generalized bone diseases 1. Paget’s disease of bone 2. Primary hyperparathyroidism 3. Osteomalacia 4. Osteoporosis

27  Localized bone diseases 1. Metastases from carcinoma breast, lung, kidney, and thyroid. 2. Multiple myeloma 3. Primary bone tumors Malignant- Osteosarcoma Chondrosarcoma Benign Osteoclastoma Bone cyst

28  1.Name- (for identification purposes)  2.Age-important to identify the disease since most of the diseases have an age distribution eg:- osteoporosis -over 50 yrs osteosarcoma yrs osteoma 40-50yrs Parosteal osteosarcoma yrs -imporatant to take decisions on surgical fitness

29 3.Sex- Osteoporosis is more common in females 4.Occupation-exposure to radioactive radium and thorium dioxide increases the risk of development of osteosarcoma 5.P/C- What has happen-(circumstance) ?accident/?deliberate harm At what time? After math-LOC/Numbness/Bleeding/ Inability to walk Time of the last meal? Intoxication?(alcohol/drugs)

30 Early fractures or any prolong immobilisation? Suffering from any illness? Wt loss (CA/TB) Change in Ht? Hx of renal stones? 6.PMHx-DM,HT,Asthma Cushing’s,Hyperthyroidism,Acromegaly CVA,fainting attack,epilepsy,hypoglysemia 7.PDHx- Corticosteroids 8.PSHx-Any previous trauma,any Sx and complications

31 9.Menstual Hx- 10.Allergies- 11.Immunisation-eg tetanus 12.Family Hx-eg-osteogenesis imperfecta osteopetrosis 13.Personal Hx-smoking,alcohol,lifestyle family life (?assault) 14.Dietary Hx-?protein and Vit deficiency? Inadequate Ca intake

32 1. General Examination 2.Examination of the Hip Joint 3. Special Examination of systems 4. Radiographical Examination

33 Patient is in pain Unable to stand Limb is shortened and lies in external rotation Skin wounds or obvious deformity

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35 Ecchymosis of the proximal thigh- occasional

36 Inspection Skin changes- Redness, swelling Shape Position Scars Wasting of gluteal and thigh muscles Palpation Temperature, tenderness over the joint Skin, soft tissue, muscles, bone Movements Voluntary, involuntary, crepitus Flexion- measured with knee bent. Opposite thigh must remain in neutral position. Flex the knee as the hip flexes. Abduction- measured from a line that forms an angle of 90 degrees with a line joining the ASISs. Adduction Rotation in flexion Rotation in extension Extension- attempt to extend the hip with the patient lying in the lateral or prone position

37 Look for, Shortening in External rotation of the involved extremity Palpation below the ingunum elicits pain Inability to move

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39 1. Circulatory system 2. Neurological Examination 3. Musculoskeletal System

40 Inspection Palpation Percussion Auscultation

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43 Examination of Associated Injuries Wrist # Head injury Most frequently associated injuries are due to patient’s osteoporosis in other areas of the body. They are sustained at the same time as the trochanteric fracture

44 AP Radiograph of the distal Pelvis AP and Lateral Radiographs of the hip joint Femur Knee joint ^

45  To Diagnose Fracture  To Find Aetiology  Preoperative Assessment  Postoperative evaluation

46  X-Ray Hip Rule of 2s 2views 2joints 2limbs 2times Rule of As Anatomy Articularv Alignment Angulation Apex Apposition  CT Scan-Not indicated in routine evaluation

47  X-ray- Osteoporosis Paget’s Disease Chondrosarcoma Lytic lesion Involves the inferior aspect of the neck and the medial intertrochanteric area.

48  Ewing sarcoma. Entire proximal part of the femur is filled with mottled sclerotic densities indicative of a diffuse pathological process.

49  CXR, X-ray pelvis, Bone scan - Metastasis  Serum Ca –Hyperparathyroidism Osteomalacia T3,T4- Hyperthyroidism  Bone marrow biopsy- Multiple myeloma

50  CXR  FBC  Hb  ECG  FBS

51  X-ray Hip To evaluate the reduction

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53  Management of fracture can be considered as,  Operative treatment  Non operative treatment  Indications for Non operative Treatment  An elderly person whose medical condition carries an excessively high risk of mortality from anaesthesia and surgery  Non ambulatory patient who has minimal discomfort following fracture

54  Skeletal traction is the most common method used to control and reduce pain  In subtrochanteric fracture most common method to reduce the fracture is by skeletal traction with a transcondylar Steinmann pin  90 degree flexion is used to relax the iliopsoas: correct the flexion and external rotational deformities  period of traction ranges from 12 to 16 weeks  should be monitored with regular radiological imaging  Early removal of skeletal traction may be followed by bracing with a hip spica cast when early callus is seen in x-ray films.  Maintenance exercise must be administered regularly to maintain the mobility of joints and muscle strength

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56  In elderly patients, this approach was associated with high complication rates  typical problems included decubiti, urinary tract infection, joint contractures, pneumonia, and thromboembolic complications, resulting in a high mortality rate.  In addition, fracture healing was generally accompanied by varus deformity and shortening because of the inability of traction to effectively counteract the deforming muscular forces

57  Surgical stabilization is the standard of care  Internal fixation of fractured end is widely performed.  Intramedullary nail fixation is the preferred treatment  Two methods  Open Method  Closed Method

58  possible in fractures with minimal comminution but it demands an extensive dissection  weight-bearing may not be possible until the fracture heals  disadvantage of the open technique is extensive soft tissue dissection  temporarily fixed with reduction forceps or Kirschner wire (K-wire) fixation; then fixed with lag screws  plate is fixed proximally to the femoral head and neck for maximal stability

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60  closed reduction and internal fixation  Closed reduction is usually performed with the use of a fracture traction table with a transcondylar Steinmann pin  fixation can be carried out with percutaneous implant insertion  most common implant used is the intramedullary locked nail  does not disturb the fracture hematoma  minimum soft tissue dissection  need to use fluoroscopy and the difficulty in performing distal locking are potential disadvantages

61  This device is indicated only for very proximal fractures.  The sliding of the screw allows medialization of the distal fragment, which reduces bending moment on fracture and implant

62  Hence this was pathological fracture we have to find the cause and treat for that.  metastatic tumours are the most common types of tumour deposits in this region  So other metastatic sites should also be investigated before definitive fixation of the fracture is performed.  In the case of primary, investigate for secondaries and follow chemotherapy / Radiation therapy

63 1.)Surgical 2.)Non surgical  Cast bracing  Hip sica cast + traction

64 Pre operative measures a)Assessment of the patient  Cormobid factors  Surgical fitness  Risk for anesthesia b)Pre operative templating - for proximal comminution the use of a fixed angle device with the proper blade and compression screw length

65 When an intramedullary device is chosen, templating for length, canal diameter is necessary for proper planning. c)Measurements  Normal side femur length

66 Surgery main techniques:  external fixation  open reduction and internal fixation a)Extra medullary implants b)Intra medullary implants

67 Extra medullary devices 1.)Sliding compression screw plate 2.)Dynamic hip screw(DHS) e.g:-DCS Indications:-  Fractures with stable configurations  Unstable fractures with an intact lateral cortex

68 Intra medulary devices 1)Intra medullary hip screw(IMHS)  Cephalomedullary nails  Reconstruction nails(centromedullary) Indications:-  Shorter nail-If fracture line doesn’t extend more than 1 to 2cm distal to lesser trochanter  Longer nail-unstable fractures

69 IMHS DHS

70 External fixation- Rarely used but is indicated in severe open fractures. For most patients, external fixation is temporary, and conversion to internal fixation can be made if and when the soft tissues have healed sufficiently.

71 Post operative period. 1.)Following intramedullary nailing if the bone quality and cortical contact is adequate, 50% partial weight bearing can be allowed immediately. With less stability, patients can perform touchdown weight bearing. Following OR and plate fixation, minimal protected weight bearing can begin immediately but is advanced slowly beginning approximately 4 weeks after surgery, with full weight bearing anticipated at 8-12 weeks. Elderly patients may have difficulty with compliance with weight bearing restrictions.

72 2.) Check for proper union 3.) Prevent infections 4.) Wound care 5.) Nutrition- high protein diet

73 Acute complications 1. Damage to nerves and blood vessels 2. Haemorrhage 3. Other soft tissue damage Long term complications 1. Failure of fixation -screws may cut out of the bone if reduction is poor or if the fixation device is incorrectly positioned. Reduction and fixation may have to be re-done.

74 2. Malunion - only complication that is frequent -may occur through bending or breakage of a nail plate or simply through compression of the soft cancellous bone with metal. -causes union with a slightly reduced neck-shaft angle- coxa vara

75 - If neglected, I. May unite with marked lateral rotation of the shaft. II. May develop severe coxa vera associated with shortenig.  Treatment 1. In most cases, can be accepted without treatment. 2. In severe deformities, -the bone is divided in the trochanteric region and the fragments are secured in the correct position by a compressive screw plate or other appropriate device(as in a fresh fracture.

76 complications due to treatments 1. casts - pressure ulcers -thermal burns -thrombophlebitis 2. Internal fixation - infections - neurological and vascular injury -thromboembolic events -avascular necrosis -posttraumatic arthritis

77  Complications of immobilization 1. Bed sores 2. Hypostatic pneumonia 3. Osteoporosis 4. Hypercalcaemia 5. Hypercaliuria 6. Urolithiasis 7. UTIs 8. Muscle wasting 9. Joint stiffness 10. DVT 11. Pulmonary embolism 12. Psychological depression

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79  Close follow-up is required following fixation  50% PWB can be allowed immediately  Wound is checked for proper healing 7-14 days post operatively DKA

80  Patient should have monthly clinical evaluations and radiographs to monitor healing.  Quadriceps rehab to be started within 02 weeks post operatively  Most patients will have significant disability for 4-6 months DKA

81  Impact activities may be possible after 06 months (Should wait 01 year before returning to full contact sports) DKA

82 Rehabilitation involves: * Ankle pumps (to prevent DVT) * Chest Physiotherapy (Airway clearance) * Exercises : Quadriceps, Hamstrings and Glutei (Isometrics) Heel Slides (in supine lying) Strengthening Ex to Upper Limbs (Before prescription of walking aids) DKA

83 Static Quadriceps Ex.

84 Static Hamstring Ex.

85 DKA Heel Slides

86 Mobility and weight bearing * Increase bed mobility (Supine to Sitting) * Increase ambulation with appropriate weight bearing (TDWB with walker -> PWB with walker) * Perform SLR (up to 6” from the bed level in supine lying) * Mini Squats DKA

87 Straight Leg Raise (SLR)

88 DKA Mini Squat/Half Squat

89  Within 1-2 Weeks * Reinforce good posture * Add standing hip abduction, adduction, extension and flexion with hip and knee flexion exercises DKA

90  Gets out of bed independently.  Able to ambulate 50 feet independently in a hall with assistive device.  In and out of bathroom independently. DKA

91  Advice to the patient on:  Changes to the home environment  Lifestyle changes  Prevention DKA

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