Case discussion

1. Case discussion

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.

4. Two types • Extracapsular • Intracapsular • Extra capsular • Trochanteric • Subtrochanteric Fracture of the femur

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. 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. First aid

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.

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

18. Primary survey and resuscitation

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

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

21. At risk in all unconscious patients. Airway and Breathing

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. Circulation

23. Head injury • Examination: Level of consciousness External wounds Pupils- dilated, unequal • CT scan of the brain Disability of CNS- AVPU

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 Paget’s disease of bone Primary hyperparathyroidism Osteomalacia Osteoporosis Differential Diagnosis-

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

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-10-25 yrs osteoma 40-50yrs Parosteal osteosarcoma-30- 60yrs -imporatant to take decisions on surgical fitness History

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

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

34. Mental and Emotional statePhysical attitude Gait Physique Face Skin Hands Feet Neck – lymph nodes, thyroid glandBreast AxillaeTPulse Respiration Odours

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 Examination of the Hip Joint

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

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

39. Circulatory system Neurological Examination Musculoskeletal System Special Examination

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

41. pallor, cyanosis, edemaPulse, BP, JVP

42. Peripheral pulses- absent means major vessel injury

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 3. Musculoskeletal System

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

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

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 Diagnose Fracture

47. X-ray- Osteoporosis Paget’s Disease Chondrosarcoma Lytic lesionInvolves the inferior aspect of the neck and the medial intertrochanteric area. Find Aetiology

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 Preoperative Assessment