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  1. 1. Interesting case 13 July 2017 Guntarat Chinvattanachot Faculty of medicine Ramathibodi hospital
  2. 2. A Thai man, 20 years old Motorcycle accident 30 minutes PTA
  3. 3. Primary survey Airway and C-spine protection can speak , no stridor able to achieve neck movements all directions without pain , not tender along posterior cervical midline , absence of focal neurological deficit , no evidence of alcohol intoxication , absence of distracting painful injury Breathing no open chest wound , RR 22/min , trachea in midline , equal chest movements and equal breath sound both lungs , chest compression test negative , absence of paradoxical movement of chest wall , neck vein not engorged
  4. 4. Primary survey Circulation vital signs : BP 119/60 mmHg , Pulse rate 130 bpm , no active bleeding , pelvic compression test negative , not tender at both thighs Disability E4V5M6 pupil 2.5 mm RTLBE
  5. 5. Primary survey Exposure multiple abrasion wounds at right knee and both arms marked swelling at left forearm , tender at mid forearm , no obvious deformity deformity of right leg as shown in the picture no wound at back , not tender along spine
  6. 6. Adjunct to primary survey Film chest x-ray Film pelvis AP FAST
  7. 7. Secondary survey Allergies : deny history of food and drug allergy Medication : no current medication Past illness : no known underlying disease Last meal : 8.00 Event : motorcycle crash with a car
  8. 8. Physical examination General appearance : A Thai adolescent man, alert, oriented to time place person HEENT : no wound on scalp and face, no periorbital ecchymosis, no abnormal discharge from ears or nose Cardiovascular : pulse full regular all extremities , no distant heart sound , normal S1 S2 , no murmur Respiratory : clear , equal breath sound both lungs , no adventitious sound
  9. 9. Physical examination Abdomen : no ecchymosis , soft , not tender , no guarding , no rebound tenderness Neurologic : alert , active , oriented to time place person , E4V5M6 , pupils 2mm RTLBE motor V/V (could not evaluate left arm and right leg due to pain) , sensory intact , DTR 2+
  10. 10. Physical examination Extremities : Right arm and Left leg : no deformity , presence of small abrasion wounds , not tender , full active ROM , intact sensation , pulse 2+ Left arm : marked swelling at left forearm , no obvious deformity , tender at mid forearm , limit elbow and wrist ROM due to pain , full ROM of fingers , intact sensation , radial pulse and ulnar pulse 2+
  11. 11. Physical examination Right leg : deformity as shown in the picture , tender at buttock area , not tender and groin thigh knee ankle and foot , no stepping limit active hip and knee ROM due to pain , passive ROM was not evaluated able to perform ankle dorsiflexion plantarflexion inversion and eversion , able to perform toes dorsiflexion plantarflexion abduction and adduction intact pinprick sensation dorsalis pedis pulse and posterior tibial pulse 2+
  12. 12. Adjunct to primary survey
  13. 13. Investigation
  14. 14. Problem lists Mild head injury ( Moderate risk) R/O blunt abdominal injury Posterior dislocation of right hip Closed fracture mid shaft of left radius
  15. 15. Initial management Stabilization Immobilization Pain control EMERGENCY🚑
  16. 16. Hip dislocation Posterior hip dislocation Anterior hip dislocation Central hip dislocation
  17. 17. Mechanism of injury
  18. 18. Mechanism of injury
  19. 19. Deformity
  20. 20. Associated injuries
  21. 21. Associated injuries
  22. 22. Radiographic finding
  23. 23. Radiographic finding
  24. 24. Classification
  25. 25. Classification
  26. 26. Management
  27. 27. Pre reduction considerations Associated injuries and fractures Neurologic and vascular injury
  28. 28. Close reduction
  29. 29. Closed reduction Video
  30. 30. Post reduction management Stability Neurovascular assessment Congruency • Plain film : 5 standard views Both hip AP , Judet views , inlet and outlet of pelvis • CT scan
  31. 31. Post reduction management Immobilization Pain control
  32. 32. Post reduction management Rehabilitation • Limit adduction , internal rotation , flexion < 60 degree • Exercise abduction, extension • Early mobilization • Partial weight bearing with gait aid 4-6 weeks
  33. 33. Operative management Indications • Associated fractures : acetabulum , femoral head , femoral neck • Irreducible dislocation • Iatrogenic sciatic nerve injury • Incongruent reduction
  34. 34. Late complications Avascular necrosis Arthritis Heterotopic ossification Sciatic nerve dysfunction
  35. 35. AVN early detection :Lack of disuse osteopenia (no resorption) relatively sclerosis -> further MRI Mx : core decompression (early treatment )
  36. 36. Take home messages
  • nattakul

    Jul. 28, 2017

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