orthopedics

1. CASE CONFERENCE
15/05/60
Ext. รดาณัฐ วิจารณ์ RA +

2. Patient profile !
,ชายไทย อายุ 19 ปี+
Chief complaint!
,ปวดสะโพกขวา เหยียดขาไม่ได้ 30 นาที ก่อนมาโรงพยาบาล +
Present illness!
,30 นาทีก่อนมารพ. ผู้ป่วยขับรถมอเตอร์ไซค์ชนกับรถเก๋ง ไม่ได้สวมหมวกกันน็อค +
ไม่มีศีรษะกระแทก ไม่สลบ ปวดสะโพกขวา เดินลงน้ำหนักไม่ได้ มีบาดแผลถลอกตามร่างกาย +
มีแผลฉีกขาดที่หน้าและต้นคอด้านหน้า ไม่มีเสียงแหบ พูดได้ +

3. Primary survey !
A : ,Airway patent , can speak , can move neck , C-spine not tender +
B : ,Equal breath sound , chest compression test negative+
C : ,V/S stable [ BP 102/60 mmHg , PR 80 bpm ] +
D : ,E4V5M6 , pupil 2 mm RTL BE+
E : ,Avulsion wound 3cm at left side of neck , no active bleeding+
,Right leg – hip adduction , internal rotation and knee flexion +
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4. Secondary survey !
A : ,no history of food/drug allergy+
M : no current medication+
P : ,no underlying , Hx Right patella fracture S/P Sx +
L : ,last meal 11.00 [50min PTA]+
E : ,as in present illness ,+
,+

5. GA : A teenager Thai male , good consciousness +
Vital sign : BT , PR , BP , RR+
HEENT : not pale conjunctiva , anicteric sclera+
Neck : avulsion wound at neck (zone I) , no active bleeding , no horseness +
Heart : normal S1,S2 , no murmur +
Lungs : no dyspnea , trachea In midline , clear , equal breath sound both lungs +
Abdomen : soft , no tenderness+
Neuro : grossly intact +
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Physical examination!

6. Extremity+
,Right leg : +
, ,position – hip adduction , internal rotation and knee flexion+
, ,abrasion wound at knee and foot +
, ,tender at right groin , can’t extend hip +
, ,posterior tibial pulse 2+ +
,Right knee : +
, ,full ROM , no tenderness , no swelling +
, ,valgus and varus stress test negative +
, ,anterior drawer and posterior drawer test negative +
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Physical examination!

8. Film!
Both hip AP

9. Film!
Judet view

10. Film!
Judet view

11. Diagnosis+
Right posterior hip dislocation !

12. HIP DISLOCATION

13. CLASSIFICATION
SIMPLE VS. COMPLEX+ ANATOMIC CLASSIFICATION+
SIMPLE!
,pure dislocation +
,without associated fracture+
COMPLEX!
,dislocation+
+ ,fx of acetabulum or proximal femur+
POSTERIOR DISLOCATION (90%)+
ANTERIOR DISLOCATION !

14. POSTERIOR HIP DISLOCATION

15. POSTERIOR HIP DISLOCATION
Presentation !
• acute pain +
• inability to bear weight+
• deformity+
• Position +
,hip and leg in slight flexion ,
,adduction, and internal rotation!

16. ! Osteonecrosis+
! Posterior wall acetabular fracture+
! Femoral head fracture+
! Sciatic nerve injuries +
! Ipsilateral knee injuries (up to 25%)+
POSTERIOR HIP DISLOCATION
Associated injury!

17. POSTERIOR HIP DISLOCATION
X-Ray!
• femoral head smaller then contralateral side+
• Shenton's line broken+
• lesser trochanter internally rotated +AP pelvis !

18. POSTERIOR HIP DISLOCATION
CT scan! • helps to determine direction of dislocation, loose bodies, and
associated fractures+
• Post reduction CT !
,in traumatic hip dislocations +
to look for femoral head fx , loose bodies , acetabular fx +

19. POSTERIOR HIP DISLOCATION
Management!
• Non-operative+
• Closed reduction +
• Operative +
• Open reduction+
true orthopedic emergencies+
should be reduced within 6 hr+
Irreducible dislocation+
Sciatic n. injury caused by reduction+
Incongruent reduction +

20. POSTERIOR HIP DISLOCATION
Management!
CLOSED REDUCTION !
under GA / sedation+
Allis method+
Stimson gravity technique+
Bigelow and reverse Bigelow maneuvers +

21. Allis method!

22. Stimson gravity technique!

23. Bigelow meneuver!

24. POSTERIOR HIP DISLOCATION
Management!
CLOSED REDUCTION !
under GA / sedation+
After reduction +
CT scan (if possible) or Film +
Both hip AP , inlet , outlet , Judet views+

25. Management!
Set OR for closed reduction under GA+

26. Both hip AP+

27. Judet viw+

28. POSTERIOR HIP DISLOCATION
Complication!
• Osteonecrosis +
relate with time of reduction+
• Post traumatic arthritis +
up to 20% for simple dislocation+
markedly increased for complex dislocation+
• Sciatic nerve injury+
• Recurrent dislocations <2%+