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Case discussion.

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Presentation on theme: "Case discussion."— Presentation transcript:

1 Case discussion

2 45 year old lady slips and falls on the ground
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.


4 Fracture of the femur Two types Extra capsular 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


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 First aid 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
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.





17 Check the pulse in the limb with the splint
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

18 Primary survey and resuscitation

19 Care of Injury – 4 Stages Prevention Pre-hospital care Hospital care
Rehabilitation “Manage the patient, Not the fracture”

20 Initial assessment and resuscitation
A = Airway B = Breathing C = Circulation D = Disability of CNS E = Exposure of the patient F = Foley catheter

21 Airway and Breathing At risk in all unconscious patients.

22 Circulation 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 Disability of CNS- AVPU
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 Differential Diagnosis-
Generalized bone diseases Paget’s disease of bone Primary hyperparathyroidism Osteomalacia Osteoporosis

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

28 History 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
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 Examination General Examination 2.Examination of the Hip Joint
3. Special Examination of systems 4. Radiographical Examination

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

34 Mental and Emotional state Physical attitude Gait Physique Face Skin Hands Feet Neck – lymph nodes, thyroid gland Breast Axillae T Pulse Respiration Odours

35 Ecchymosis of the proximal thigh- occasional

36 Examination of the Hip Joint
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 Haematoma or bruit over the area suggest arterial damage .
Look for, Shortening in External rotation of the involved extremity Palpation below the ingunum elicits pain Inability to move

38 Additional examinations of hip joint : Measurement of True and apparent shortening

39 Circulatory system Neurological Examination Musculoskeletal System
Special Examination Circulatory system Neurological Examination Musculoskeletal System

40 Inspection Palpation Percussion Auscultation
1. Circulatory System why? 1) Cardiovascular syncopy or initial stroke could have caused the fall 2) Detect other cardiovascular problems Inspection Palpation Percussion Auscultation

41 pallor, cyanosis, edema Pulse, BP, JVP

42 Peripheral pulses- absent means major vessel injury

43 3. Musculoskeletal System
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 Radiographic Examination
AP Radiograph of the distal Pelvis AP and Lateral Radiographs of the hip joint Femur Knee joint ^

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

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

47 Find Aetiology 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,T Hyperthyroidism Bone marrow biopsy- Multiple myeloma

50 Preoperative Assessment

51 Postoperative evaluation
X-ray Hip To evaluate the reduction

52 Treatment

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 Non operative management
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 Hare traction, Buck's traction

55 Position of patient in treating subtrochanteric fractures with skeletal traction

56 Complications 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 treatment 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 Open Method 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


60 Closed Method 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 Sliding hip screw 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 Other treatment 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
Assessment of the patient Cormobid factors Surgical fitness Risk for anesthesia Pre operative templating - for proximal comminution the use of a fixed angle device with the proper blade and compression screw length

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

66 open reduction and internal fixation Extra medullary implants
Surgery main techniques: external fixation open reduction and internal fixation Extra medullary implants 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


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 ) Nutrition- high protein diet

73 Complications Acute complications Long term complications
Damage to nerves and blood vessels Haemorrhage Other soft tissue damage Long term complications 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 -only complication that is frequent
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, Treatment
May unite with marked lateral rotation of the shaft. May develop severe coxa vera associated with shortenig. Treatment In most cases, can be accepted without treatment. 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
casts -pressure ulcers -thermal burns -thrombophlebitis Internal fixation -infections -neurological and vascular injury -thromboembolic events -avascular necrosis -posttraumatic arthritis

77 Complications of immobilization
Bed sores Hypostatic pneumonia Osteoporosis Hypercalcaemia Hypercaliuria Urolithiasis UTIs Muscle wasting Joint stiffness DVT Pulmonary embolism Psychological depression

78 Follow up and Rehabilitation

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

80 Quadriceps rehab to be started within 02 weeks post operatively
DKA 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

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

82 Rehabilitation Rehabilitation involves: * Ankle pumps (to prevent DVT)
DKA Rehabilitation 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)

83 Static Quadriceps Ex.

84 Static Hamstring Ex.

85 DKA Heel Slides

86 DKA 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

87 Straight Leg Raise (SLR)

88 DKA Mini Squat/Half Squat

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

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

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

92 Thank You

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