5. Primary Survey
A: patent airway, can talk, no c-spine
tenderness, can rotate neck
B: trachea in midline, clear equal breath
sound both lungs, RR 16 tpm, CCT –ve
C: BP 139/75 mmHg, PR 97 bpm, no
external active bleeding
D: E4V5M6, pupils 2 mm RTLBE
E: Lt. hip – externally rotated, abducted,
limited ROM due to pain
6. Secondary Survey
A: no history of food/drug allergy
M: current medication: Folic acid 1x1 PO pc,
Furosemide (40) 0.5x1 PO pc, Spironolactone
(25) 2x1 PO pc, Vit B Co 1x3 PO pc, Lactulose 30
mL PO prn constipation
P: U/D decompensated alcoholic liver cirrhosis
F/U MNRH on med, last admission 11-15/7/61
presented with AoC with fever, DDx hepatic
encephalopathy, septic (UTI) encephalopathy
L: 17.00, 20/9/61
E: as in Present Illness
7. Physical Examination
V/S: BT 37.3 C, BP 139/75 mmHg, PR 97
bpm, RR 16 tpm
HEENT: mild pale conjunctivae, mild icteric
sclerae
CVS: normal S1S2, no murmur
Lungs: clear equal breath sound both lungs,
CCT –ve
Abdomen: not distended, soft, not tender
8. Physical Examination
Rt. Leg: no external
wound, localized marked
tenderness at upper
thigh, externally rotated,
abducted, limited ROM
of hip due to pain
DPA 2+, PTA 2+,
capillary refill <2 sec.
Pinprick sensation intact
20. Introduction
Extracapsular fractures of the proximal femur
between the greater and lesser trochanters
Most common history taking: pain around the
hip, inability to ambulate after injury
Physical Exam: painful, shortened, externally
rotated lower extremity (greater trochanter:
abduct and externally rotated by gluteus
medius and short external rotators)
22. Introduction
Most common associated injuries
Low enerygy fall: distal end radius fracture,
proximal humerus fracture, mild head injury
High energy trauma: ipsilateral extremity
trauma, head injury and pelvic fracture.
23. Introduction
20-30% mortality risk in the first year
Factors that increase mortality
higher in intertrochanteric fracture (vs. femoral
neck fracture)
operative delay of >2 days
age >85 years
2 or more pre-existing medical conditions
ASA classification III and IV increases mortality
24. Laboratory Investigations
Routine pre-op lab.
Osteoporosis: vit D, PTH, TSH
Malnutrition and vitamin D deficiency: serious
risk factors for mortality and recovery
Current recommendations; administer 50,000
IU of Vit. D immediately to all elderly patients
on admission with hip fracture
28. Management
Surgery vs. Conservative
Surgery: greater pain relief, improved early
patient mobility, lower mortality rate
Non-operative management indications
Non ambulatory or chronic dementia
Terminal disease, < 6 wks life expectancy
Unresolvable medical comorbidites
29. Non-operative Management
Nonweightbearing with early out of bed to
chair
Skin traction for 6 weeks, then lift into wheel
chair or reclining chair
Frequent positioning, nutritional support, fluid
homeostasis, adequate pain control
high rates of pneumonia, UTI, pressure sore,
DVT
30. Operative Management
Recommend early surgery within 24-48 hrs
(decreased hospitalization time, reduced post-
op complications)
31. Operative Management
Sliding hip compression
screw
indications
stable type
outcomes
equal outcomes when
compared to intramedullary
hip screws for stable fracture
patterns
33. Operative Management
Arthroplasty Indications
severely comminuted fractures
preexisting symptomatic degenerative arthritis
osteoporotic bone that is unlikely to hold internal
fixation
salvage for failed internal fixation
34. Post-op Complications
Thromboembolic phenomenon
Infection
Non union/malunion
Implant failure and cut-out
Anterior perforation of the distal femur
(intramedullary screw fixation)