Education

1. Discuss the Differential Diagnosis and
Management of a 65yrs Old Community
Ambulant Man with 6hrs History of Left
Hip Pain and Inability to Bear Weight
Following Fall from Standing Height
Dr. Arojuraye, S. A
(Senior Registrar)
National Orthopaedic Hospital, Dala - Kano
9th February, 2018

2. Outline
 Introduction
 Differential diagnosis
 Management
 Resuscitation
 History
 Examination
 Investigations
 Treatment
 Complications
 Conclusion

3. Introduction
 65yrs old man (Elderly)
 Community ambulant
 Hip pain & inability to bear weight
 Fall from standing height (Trivial fall)

4. Differential Diagnosis
 Fracture around the left hip
 Fracture NOF
 Intertrochanteric #
 Subtrochanteric #
 Pathological
 Fragility #
 Metastasis
 Multiple myeloma
 Chronic osteomyelitis

5. Management
 Resuscitation
 ATLS protocol
 Analgesia
 Skin traction
 DVT prophylaxis

6. Management
History
 Age (65yrs)
 Gender (M)
 Lt hip pain
 Inability to bear weight
 Fall from standing height

7. Management…
History…
 Prior hip pain
 Urinary tract symptoms
 Previous surgery
 Recurrent discharge
 Drugs
 Steroids
 Anticonvulsant
 Anticoagulant
 Diuretics

8. Management…
History…
 Smoking, Alcohol
 Family hx fragility #
 Syncopal attack
 Chest pain
 Visual impairment
 Cognitive impairment

9. Management…
During old age a person is
susceptible to MOF &
perhaps lives with
compromised vital organs

10. Management…
Examination
 General
 Chest
 CVS
 Abdomen
 Rectal exam

11. Management…
Examination
 Undisplaced #
 Tenderness
 Auscultation Lippmann test

12. Management…
Examination…
 Displaced #
 Helpless attitude of the limb
 Flexion
 Abduction
 Ext. rotation
 Shortening
 Tenderness

13. Management…
Investigations
 Plain radiographs(AP/Lat)
 Diagnosis
 Classification
 CT
 More accurate
 More radiation!

14. Garden classification

15. Boyd & Griffin Classification

16. Seinsheimer classification

17. Management…
Investigations
 DEXA
 PSA
 Chest x-ray
 Serum protein electrophoresis
 Serum Ca, PO4, ALP

18. Management…
Investigations…
 GXM
 FBC, ESR
 Urinalysis
 FBS
 Renal fxn test
 Chest xray
 ECG

19. Treatment
Goals of treatment
 Minimize discomfort
 Restore hip function
 Rapid mobilization
 Anatomic reduction
 Stable internal fixation
 Prosthetic replacement

20. Management…
Non-operative
 Undisplaced #
 Decline surgery
 Mobilized touch weight-bearing with crutches
 Expected to heal 6 weeks
 Risk of displacement

21. Management…
Operative
 Timing: within 48hours

22. Management…
Operative
 Undisplaced femoral #
 Cannulated screws
 DHS

23. Management…
Operative
 Displaced femoral neck #
 Cementless THR
 Better functional outcome
 Eliminates potential for acetabular erosion

24. Management…
Operative
 Stable intertrochanteric #
 DHS

25. Management…
Operative
 Unstable intertrochanteric #
 Cephalomedullary nail

26. Management…
Operative
 Subtrochanteric #

27. Management…
Post operative
 Analgesia
 Antibiotics (8hrs, 16hrs)
 Nutrition
 Drain
 Sutures
 Physiotherapy
 Discharge

28. Management…
Post operative…
 Bisphosphonate
 Ca & Vit D
 Adjuvant chemotherapy

29. Complications
 DVT
 Pressure injury
 Orthostatic pneumonia
 Perioperative mortality
 Infections
 Implant failure
 Periprosthetic fractures

30. Conclusion
 9/10 hip # occur in the elderly
 Prevention
 Lighting should not be too dim or too direct
 Light switches should be accessible
 Carpets & rugs should be tacked down
 Bathrooms should have a chair for bathing
 Skid-resistant mats, grab bars
 Chairs need to be stable and have arm rests
 Kitchen items should be at waist level
 Stairways need handrails & steps shouldn't be slippery