I-Hip Fracture kanye ne-Traumatic Hip Dislocation: Ukuhlolwa kwe-Neurovascular and Immobilization¶

Ngemva kokuwa ohlangothini lwe-hip kumuntu omdala omdala noma ukushayisana kwemoto enamandla amakhulu, ukushayisana kwe-ski, noma ukuwa kusukela ekuphakameni, ubuhlungu obukhulu be-groin noma i-buttock ngokungakwazi ukuma noma ukuphakamisa umlenze kubonisa ukuphuka kwe-** proximal femur (hip) ** noma ** ukuhlukaniswa kwe-hip okuhlukumezayo **. Ukubheka nje ukuma kokuphumula komlenze olimele uma kuqhathaniswa nomlenze ongalimele kuveza okwenzekile ngaphakathi kwesihlanganisi: **intamo yesifazane noma i-intertrochanteric hip fracture ** ishiya umlenze ifinyeziwe futhi ijikelezwe NGAPHANDLE (ijikelezwe ngaphandle) ngakho umkhawulo ongaphandle wonyawo uhlala phansi phansi, noma amaphesenti angu-9 **hip ukugudluka, ngokwejwayelekile ukusuka edolweni elishaya ideshibhodi yemoto) ikhiya umlenze ufinyezwe, ugobe, udonse umugqa omaphakathi, futhi uzungezise NGAPHAKATHI (uzungeziswe ngaphakathi). Ngenxa yokuthi ikhanda lesifazane elihlanjululwe linweba imithambo emincane yezakhi ezondla ibhola le-hip futhi lichoboze i- **sciatic nerve ** ngqo ngemuva kwesokhethi, **konke ukukhishwa kwe-hip okuhlukumezayo kufanele kubuyiselwe endaweni ngaphansi kwe-sedation kungakapheli amahora angu-6 ** ukuvimbela ukufa unomphela kwethambo (**i-avascular necrosis **) nokukhubazeka konyawo impilo yonke. Shayela inombolo yakho yasendaweni yezimo eziphuthumayo ngokushesha nge izinombolo eziphuthumayo, futhi ubuyekeze ukunakekelwa okuhlobene nokuhlukumezeka ku ukuqiniswa kwe-pelvic fracture kanye ne-hemorrhage yangaphakathi, amathambo aphukile kanye nama-sprains, futhi ukuqashelwa ukushaqeka nokunakekelwa.

Yenza lokhu manje¶

1. Shayela inombolo yakho yasendaweni yezimo eziphuthumayo ngokushesha (911 e-United States nase-Canada, 112 ku-European Union yonkana, 999 e-United Kingdom). Ungalokothi uzame ukucosha umuntu okusolakala ukuthi uqhekeke inqulu noma i-hip dislocation ngaphansi kwezingalo zakhe ukuze umhambise esihlalweni noma emotweni yangasese; ukuma noma ukusonta i-femoral neck crack engasuswanga endaweni kunganqamula ibhuloho elisele lethambo, kudabuke imithambo yegazi ye-retinacular esondla ikhanda lesifazane, noma kuqhubezele i-intertrochanteric bone spike emthanjeni omkhulu we-pelvic.
2. Shiya umlenze lapho ogobile khona noma owuphendukile owutholile bese uwupheqa ngemicamelo, izingubo zokulala ezigoqiwe, noma amabhantshi. UNGALINGE uzame ukuqondisa, ukudonsa ukudonsa, noma ukuzungezisa inqulu ekhubazekile endaweni yesigameko.* Lapho kugudluka inqulu noma ukuphuka kwentamo yesifazane, ukuphoqa umlenze uqonde, ukunqamula inzwa ** i-artery**, noma nqamula intamo yesifazane khona lapho ibhola linamathele ngaphandle kwesokhethi.
3. Yenza "30-Second Distal Sciatic Nerve and Arterial Check" onyaweni khona manje bese ukuphinda njalo emizuzwini eyi-15:
4. Hlola i-Peroneal Division ye-Sciatic Nerve (Esengozini Kakhulu Ku-Posterior Hip Dislocation): Cela isiguli ukuthi sidonsele izinzwane zabo ezinkulu nonyawo PHEZULU ukuya ekhaleni labo (i-ankle kanye ne-dorsiflexion enkulu yezinzwane) futhi uthinte phezulu konyawo lwabo kanye nendawo yewebhu phakathi kwezinzwane zokuqala nezesibili ukuze uqinisekise umuzwa ovamile.
5. **Hlola i-Tibial Division ye-Sciatic Nerve: ** Cela isiguli ukuthi **phushe unyawo lwaso PHANSI njengokucindezela i-gas pedal (plantarflexion) ** futhi uthinte phansi konyawo lwazo.
6. Hlola I-Distal Arterial Pulses kanye Nokugcwalisa Kabusha Kwe-Capillary (Kubalulekile Ekususweni Nokuqhekeka Kwe-Hip Kwangaphambili): Izwa ukushaya kwenhliziyo kwi-arch engaphezulu yonyawo (dorsalis pedis artery) nangemuva kwethambo leqakala elingaphakathi (posterior tibial artery), bese ucindezela u-pink2 umbala ukubuya. Qhathanisa ukufudumala kwesikhumba ngokumelene nonyawo olungalimalanga.
7. Uma isiguli singakwazi ukudonsa unyawo lwaso/uzwane olukhulu UP (ukwehla konyawo) NOMA uma unyawo luphaphathekile, lubanda, noma lungenawo umoya: Tshela i-911 / 112 / 999 i-dispatcher kanye nabezimo eziphuthumayo ngokushesha ukuthi kukhona ukushoda kwe-neurovascular acute (sciatic nerve palsy noma i-femoral arterial compromise) idinga i-Traumadic Center edingekayo.
8. Gcina isiguli sifudumele ngezingubo zokulala Ngaphansi Nangaphezulu komzimba waso ukuze kuvinjelwe i-conductive hypothermia. Abantu abadala asebekhulile abawela kumathayela abandayo okugezela, amagaraji kakhonkolo, noma indawo egandayiwe ngamatshe balahlekelwa izinga lokushisa lomzimba eliyisisekelo ngokushesha phansi, okwenza kube ne- hypothermic coagulopathy ebulalayo eyenza ukopha kwangaphakathi kube kubi kakhulu okuvela enqulwini noma ekuqhekekeni kwe-pelvic.
9. Gcina isiguli singenalutho nhlobo ngomlomo (i-NPO: ukudla okuyiziro, amanzi angu-zero, kanye namaphilisi ezinhlungu zomlomo angenawo). Ukususwa kwe-hip okubuhlungu kudinga ukucwiliswa kwenqubo ye-intravenous ngokushesha (noma i-anesthesia evamile egumbini lokuhlinza) phakathi namahora, futhi ukuphuka kwe-hip kudinga ukulungiswa kokuhlinzwa phakathi kwamahora angu-24 kuya kwangu-48; ukudla noma amanzi esiswini kubambezela i-anesthesia noma kwandisa ingozi yokufisa.
10. Hlola ukuhlukumezeka kwekhanda ngesikhathi esisodwa, ukusetshenziswa kokunciphisa igazi, kanye nezimbangela zezokwelapha ezifihliwe zokuwa. Buza ukuthi kungani umuntu ewile (isiyezi, ubuhlungu besifuba, ukuba mnyama, noma ukukhubeka) futhi uhlole ukuthi uyawaphuza yini ama-anticoagulant (apixaban, rivaroxaban, dabigatran, warfarin, noma clopidogrel), njenge-subtrochanteric orhip intertrochanteric 1.0 kuya ku-2.0 amalitha (2 kuya ku-4 amaphayinti) wegazi ngaphakathi emisipha yethanga.

Isihlahla sesinqumo: Ukuma komlenze obonakalayo kanye ne-neurovascular triage in acute hip trauma¶

flowchart TD
    Start["Ubuhlungu Obunzima Be-Hip, Groin, noma Buttock + Ukungakwazi Ukuthwala Isisindo Ngemva Kokuwa noma Ukuphahlazeka"] --> PostureCheck{"Hlola Ukuma Nokushintsha Komlenze Uma Kuqhathaniswa Nomlenze Ongalimele"}

    PostureCheck -->|"Umlenze OMFUSHANE futhi Uzungeziswe NGAPHANDLE (Uzungeziswe Ngaphandle, Unyawo Lukhombe Eceleni) NOMA Ukuqondanisa Okubukeka Okujwayelekile Nobuhlungu ku-Axial Heel Tap / Log-Roll"| FractureOrAnt{"Ingabe lokhu bekuwukuwa Komuntu Omdala Omdala / Umthwalo We-axial, NOMA Ukuhlukumezeka Kokuzungezisa Kwangaphandle Okuphoqelelwe Umlenze Obanzi?"}

    FractureOrAnt -->|"Ukuwa / Umthwalo we-Axial (Umlenze ulala phansi embhedeni, ufinyeziwe futhi uzungeziswe ngaphandle)"| HipFracture["SOLWA UKUQHUKA KWE-PROXIMAL FEMUR (HIP) (I-Femoral Neck, Intertrochanteric, noma i-Subtrochanteric): 1. Immobilize flat ngemicamelo phakathi kwamadolo; ZERO ukuhamba. 2. Gada ukulahleka kwegazi okufihliwe (1 kuya ku-2 L ekuqhekekeni kwe-extracapsular). 3. Ukuthutha Ukuya Esibhedlela ukuze uthole i-X-ray (noma i-MRI uma kuphuke imimoya) Nokuhlinzwa phakathi kwamahora angu-24 kuya kwangu-48."]

    FractureOrAnt -->|"Ukuthunjwa Okuphoqelelwe Amandla Aphezulu + Ukuzungezisa Kwangaphandle (I-Hip ibanjwe yabanzi ibheke eceleni, izungeziswe ngaphandle, isigaxa sekhanda lesifazane esizwakalayo e-groin)"| AntDislocation["UKUHLUKA KWE-HIP ENGAPHAMBILI (10% Wokugudluka): 1. Bheka I-Femoral Artery / Dorsalis Pedis Pulse & Femoral Nerve (Inzwa Ye-Quad/Inner Calf) NGOKUSHESHA. 2. Iphedi isendaweni etholakele; ZERO ukuqondisa. 3. Shayela ku-911 / 112 / 999 ukuze uthole Ukwehliswa Okuvaliwe kungakapheli Amahora angu-6."]

    PostureCheck -->|"Umlenze OMFUSHANE, Uguquguquke, Udonswe Emgqeni Ophakathi nendawo (UDUCTED), futhi Uzungeziswe NGAPHAKATHI (Uzungeziswe Ngaphakathi, Idolo/Izinzwane Zikhombe Ngaphakathi)"| PostDislocation["UKUDUKA KWE-HIP YANGEMVA (Ama-90% Wokuhlukaniswa Komdabu Nokwenziwa Kwezinzwa, isb., Umthelela we-Dashboard Knee): 1. Hlola i-SCIATIC NERVE ngokushesha (Ingabe isiguli singadonsa uzwane/unyawo PHEZULU?). 2. Idolo/ithanga lephedi endaweni egobile ngayo; UNGALINGE ufake i-traction splint. 3. Shayela ku-911 / 112 / 999 -> Ukuncishiswa Okuphuthumayo Okuvaliwe ngaphakathi < Amahora angu-6 ukuvimbela i-Avascular Necrosis (AVN)."]

I-Pathophysiology: Ukunikezwa kwegazi kwelunga le-hip nokuthi kungani iwashi lamahora angu-6 libalulekile¶

1. Ukubuyiselwa kabusha kwegazi okuyingozi kwekhanda lesifazane¶

Ngokungafani namathambo amaningi emzimbeni athola ukugeleza kwegazi okuvulekile okuvela kokunamathiselwe kwemisipha ezungezile, ibhola le-hip joint (**ikhanda le-femoral **) lihlala livalwe ngokuphelele ngaphakathi kwe-capsule ye-fibrous engangenisi amanzi yesokhethi ye-hip (**intracapsular **), embozwe uqwanga oluthambile olungenakho okunamathiselwe kwemisipha: - Kubantu abadala, umthambo othi ligamentum teres (umthambo we-foveolar) osemaphethelweni ebhola uthwala cishe ukugeleza kwegazi okungasho lutho (ngaphansi kwamaphesenti angu-5 kuya kwangu-10). - Kunalokho, ngaphezu kwamaphesenti angu-90 egazi eligcina lonke ikhanda lesifazane liphila livela emithanjeni ethambile eyindandatho engaphansi kwentamo yesifazane eyakhiwe I-Medial and Lateral Femoral Circumflex Arteries (amagatsha e-profunda femoris / umthambo ojulile wesifazane). - Kusukela ku-Medial Femoral Circumflex Artery, amagatsha amancane akhuphukayo abizwa ngokuthi i-retinacular arteries (lateral epiphyseal arteries of Trueta) akhuphuka phezulu (retrograde) eduze kwendawo engaphandle yentamo yensikazi ewumngcingo, ibhoboza ikhepisi ukuze kondle ikhanda elithwala isisindo le-femoral.

2. Kungani Ukuphuka Kwe-Intracapsular Nokususwa Kwe-Hip Kudala I-Avascular Necrosis (AVN)¶

Ukuqonda leyo mithambo emincane ye-retinacular ebambelela entanyeni yesifazane kuchaza lonke isu eliphuthumayo ekuhlukumezekeni kwe-hip: - Ekususweni Kwe-Hip Okuhlukumezekile (Ngemuva noma Ngaphambili): Lapho ibhola le-femur lihlwithwa ngamandla liphuma kusokhethi ye-acetabular, i-ligamentum teres ihlwitha ngokuphelele futhi imithambo ye-retinacular ngasentanyeni yesifazane iyanwetshwa, ikhiqizwe, futhi icindezelwe unqenqema lwesokhethi. - Iwindi Lokusinda Lamahora Ayisi-6: Ucwaningo lwezokwelapha lwamathambo lufakazela ukuthi uma inqulu yomdabu ehlukanisiwe yehliswa ibuyele esokhethini yayo phakathi namahora angu-6 okuphahlazeka, izinga elithi Avascular Necrosis (AVN / Osteonecrosis of the femoral head) lingamaphesenti angu-5 ukuya kwangu-10* kuphela. Uma ukuncishiswa kubambezelekile ngaphezu kwamahora angu-6, izinga lokufa kwamathambo unomphela kanye nokuwa kwamalunga likhuphuka lifinyelele ku-40 kuya kumaphesenti angu-50*, okudinga ukushintshwa kwe-hip isiyonke ngisho nasesigulini esineminyaka engu-20 ubudala. - Ekuphukeni Kwentamo Ye-Femoral Ekhishiwe (I-Subcapital noma I-Transcervical): Ulayini wokuphuka oqhekezeka phakathi kwentamo yesifazane ngaphakathi kwekhephusuli elihlanganyelwe ligunda imithambo ye-retinacular phakathi. Okubi nakakhulu, uma ukuphuka kungukuthi *okungasuswanga * (imikhumbi ye-retinacular isaqinile), ukopha ngaphakathi kwe-capsule ehlangene eqinile, eqinile kudala i-*intracapsular tamponade ** eklinya ukugeleza kwe-venous kanye ne-arterial kuze kube yilapho incindezelwe ngokuhlinzwa noma ilungisiwe. - Ekuqhekeni Kwe-Hip Extracapsular (I-Intertrochanteric noma i-Subtrochanteric): Ngenxa yokuthi umugqa wokuphuka uhlala ngaphandle nangaphansi kwekhepsuli ye-hip ehlangene ngokusebenzisa ithambo elicebile, elisusa imithambo phakathi kwama-trochanter amakhulu namancane, ukuhlinzekwa kwegazi ekhanda lesifazane kuhlala kunjalo (i-AVN ayivamile). Kodwa-ke, ngenxa yokuthi ukuphuka kungaphandle kwe-capsule kungekho lutho oluthinta ukopha, i-intertrochanteric noma i-subtrochanteric fracture yopha ngokukhululekile ezicutshini ezithambile zethanga (ukulahlekelwa yi-1,000 kuya ku-2,000 millilitres wegazi), okubeka iziguli esezikhulile kanye nalabo abasengozini ye-blood thinner ** ukwethuka**.

3. Kungani Ukukhishwa Kwe-Posterior Hip Kuchoboza I-Sciatic Nerve (10% kuya ku-20% Isigameko)¶

I- **sciatic nerve ** (i-nerve ewugqinsi emzimbeni womuntu, ethwele i-L4, L5, S1, S2, kanye ne-S3 fibers elawula ama-hamstrings kanye nayo yonke imisipha eyodwa engaphansi kwedolo) iphuma e-pelvis ngokusebenzisa inotshi enkulu ye-sciatic futhi igijima ** ngqo ngaphesheya (odonga olungemuva) lwesokhethi ye-hip . - Uma idolo lomshayeli noma lomgibeli lishaya ideshibhodi phakathi nengozi yemoto engaphambili ngenkathi inqulu igobile futhi idonswa, i-femur yenza njengenqama eshayayo, ishayela inhloko yesifazane iqonde emuva iqonde emuva nge-capsule yangemuva (futhi ivame ukusika ingxenye yodonga lwe-posterior acetabular) kwesokudla uye kwinzwa **cia. - ** I-Anatomical Quirk (Okwenza I-Peroneal Division Ihlupheke Kuqala): ** Ngaphakathi kwe-trunk ye-nerve eyinhloko ye-sciatic e-hip, izinyanda ze-nerve sezivele zihlukaniselwe ku-*common peroneal (fibular) division ** (ehlezi ngaphezulu ** i-laterally nangaphezulu , iboshwe ngokuqinile entanyeni nasesifundeni) division (ehlala phakathi nendawo futhi enokuxega okwengeziwe). Ngakho-ke, ukukhishwa kwe-hip yangemuva cishe kulimaza njalo ** ukuhlukaniswa komuntu kuqala **, okubangela ** ukwehla kwezinyawo okunamandla (ukungakwazi ukuphakamisa unyawo noma uzwane olukhulu phezulu) kanye nokuba ndikindiki ngaphezu konyawo **, ngisho nalapho ukuhlukaniswa kwe-tibial (ukukhomba unyawo phansi) kusasebenza.

Ukuqhathanisa okuyinhloko komtholampilo: Ukuma komlenze kuhlukanisa kanjani ukulimala kwe-4 acute hip¶

Ezindaweni zengozi noma endaweni ye-triage bay, hlola imilenze yesiguli elele phansi noma uhlaka ngaphambi kokuyithinta:

Isicupho esikhethekile somtholampilo: "I-Occult" noma Ukuphuka Kwe-Hip Okuthintekile (Ukuhamba Ngenqulu Ephukile)¶

Ingabe umuntu angaphuka inqulu uma esakwazi ukuma, athathe izinyathelo ezimbalwa ezibuhlungu, futhi enomlenze othi hhayi mfushane noma obheke ngaphandle? - YEBO (amaphesenti angu-5 kuya kwayi-10 akho konke ukuphuka kwenyonga). Engadini Isigaba I-Garden I Engaphelele noma I-Valgus-Impacted Femoral Neck Fracture (lapho amathambo amabili aphukile aminyene aminyene njengamaconsi amabili ka-ayisikhilimu) noma ukuphuka kwengcindezi okungagudluki, umlenze, umlenze ubheke emtholampilo noma ubheke phezulu 10 hamba uye endlini yokugezela izinsuku ezingu-2 kuya kwezi-3 ukhononda kuphela "umsipha we-groin odonsiwe" noma "ubuhlungu obungachazeki bamadolo" (ngoba i-obturator nerve inikeza kokubili i-capsule ye-hip kanye nedolo elingaphakathi, i-hip pathology ivame ukudala **ubuhlungu obuzwayo buzwakala kuphela edolweni **). - Ingozi Yokuhamba Ekuqhekekeni Kwe-Hip Okuthintekile: Uma ukuphuka kwentamo ye-femal okunomthelela noma okunokusebenzelana kwemimoya kweqiwa futhi isiguli siqhubeka nokuthwala isisindo ekhaya, ithambo elithintekile liyashabalala kungazelelwe (**ukufuduka kwesibili **). Leso siliphu siguqula ukuphuka okulula okungahle kulungiswe emizuzwini engu-20 ngezikulufo ezintathu ezincane ze-percutaneous (ukugcina ibhola le-hip lemvelo lesiguli) libe yi-fracture esusiwe ngokuphelele ngemithambo yegazi edabukile edinga enkulu ** i-hemiarthroplasty noma i-hip total replacement **. - Ungakuhlola Kanjani Ukuqhekeka Kwe-Hip Okusolwayo Ngokuphephile + Umthetho We-MRI: 1. I-Gentle Heel-Strike (Axial Loading) kanye Nokuhlolwa Kwe-Log-Roll: Uma isiguli esikhulile siwa futhi sikhononda ngobuhlungu be-groin, ithanga, noma idolo naphezu kokuma okuvamile komlenze, ungalokothi usicele ukuthi sisukume. Isiguli silele sicaba, gingqa kancane umlenze okhululekile uwukhiphele ngaphandle nangaphandle njengogodo (Log-Roll Test, ukuqondisa okuqondile kokuhlolwa komzimba kwe-intra-articular hip pathology) noma uthephe phansi isithende kancane ubheke okhalweni. Ubuhlungu be-groin obubukhali bubonisa ukuphuka kwe-hip kuze kube yilapho kufakazelwa ngenye indlela. 2. Kungani I-Plain X-Rays Iphuthelwa Amaphesenti angu-2 kuya kwangu-10 Okuphuka Kwe-Hip: I-pelvis evamile ye-anteroposterior (AP) kanye nama-X-ray e-hip ahambisana ne-cross-table aphuthelwa kufika ku- 2 kuya kumaphesenti angu-10 entamo ye-femoral engasuswanga noma i-osteoporotic kanye nokuphuka kwe-intertrochanteric. 3. Igunya Lomhlahlandlela Womtholampilo (AAOS & NICE): Uma isiguli sinenyonga eqhubekayo, inyonga, noma ithanga noma singakwazi ukuthwala isisindo ngemva kokuwa futhi i-X-ray yenyonga yaso yokuqala ibukeka "evamile," AKUMELE zithunyelwe ekhaya ukuze zihambe ngayo. Ukuhlolwa okujwayelekile kwegolide kuyi-i-MRI engaphambanisi ngokushesha ye-hip (amaphesenti angu-100 azwela i-occult bone marrow edema kanye nemigqa yokuphuka kwe-trabecular) noma ukulungiswa okuphezulu ** i-CT scan ye-hip ** uma i-MRI ingatholakali noma iphikisana.

I-Native vs. Prosthetic Total Hip Replacement (THA) Ukususwa¶

1. Ukususwa Kwe-Hip Yomdabu (Isimo Esiphuthumayo Sokulimala Kwamandla Aphezulu)¶

Ngoba isokhethi ye-hip yabantu abadala ijulile, iqiniswe ugqinsi i-iliofemoral ligament ye-Bigelow (umsipha onamandla kunawo wonke emzimbeni womuntu), futhi izungezwe imisipha enamandla ye-gluteal kanye ne-iliopsoas, ukuqaqa inqulu yemvelo kudinga amandla amakhulu obudlova (ukuphahlazeka kwemoto ngesivinini esiphezulu, ukushayisana kwesithuthuthu, isitimela sokuphuma, ukuphahlazeka kwesithuthuthu) - Amaphesenti angu-95 eziguli ezinokuguqeka kwenyonga okubuhlungu okudabukisayo zinezingozi ezinkulu zokuhlukumezeka ngesikhathi esisodwa: Njalo hlola ukulimala edolweni (izinyembezi zangemuva ze-cruciate ligament, ukuphuka kwe-patellar, noma ukuphuka komphini wesifazane kusukela kumthelela wedeshibhodi; qaphela ukuthi i-ipsilateral shaft yangaphakathi ingxenye ye-postfracture yangaphakathi ngesikhathi esifanayo ukukhishwa kwe-hip, okubangela amaphesenti angu-50 wokuguquguquka kwe-hip ukuthi aphuthelwe ekuqaleni lapho ukuphuka kwe-femur kukhona), ukuphuka kwe-pelvic, ukopha ngaphakathi kwesisu, noma ukuhlukumezeka esifubeni/ekhanda. - Kungani I-X-Ray Yangaphambi Kokunciphisa / I-CT Ibalulekile Ngaphambi Kokudonsa I-Hip Yomdabu: Ngaphambi kokwenza ukunciphisa okuvalekile ngaphansi kokudakwa okujulile (usebenzisa i-Allis maneuver, uCaptain Morgan maneuver, noma i-East Baltimore Lift), odokotela bathola i-X-ray ye-pelvis ye-AP esheshayo ukuze baqiniseke ukuthi ayikho i-neck fracture** Uma udokotela edonsa ngenkani inqulu egudlukile nayo enomugqa woboya entanyeni yesifazane, intamo yesifazane inqamuka ngokuphelele, kushiye ikhanda lesifazane elifile libhajwe ngaphakathi esinqeni futhi kudinga ukuhlengwa okuvulekile kokuhlinzwa. - Igunya Le-CT Scan Ngemva Kokwehliswa: Ngemva kokuba konke ukugudluka kwenqulu yomdabu kubuyiselwe endaweni, ukuskena kwe-CT scan yepelvic kuyimpoqo ukuze kuhlolwe izicucu zamathambo eziboshiwe ezingaphakathi kwe-articular ngaphakathi kwesikhala esihlangene (ezizogaya uqwanga uma lungakhishiwe) kanye nokuhlehlisa* noma iluphi udonga* Plating okuhlinzwa.

2. I-Prosthetic Total Hip Arthroplasty (THA) Ukususwa (Isimo Esiphuthumayo Esisezingeni Eliphansi)¶

Ngokungafani nenqulu yomdabu, isiguli esike saba ne- Total Hip Replacement (Ingqikithi Ye-Hip Arthroplasty, THA) ifakwe i-capsule yaso yemvelo ehlangene futhi yafakwa esikhundleni sebhola elincane lensimbi/i-ceramic kanye nomugqa wesokhethi we-polyethylene. Cishe **1 kuya ku-3 iphesenti yokushintshwa kwe-hip eyinhloko ** (futhi kufika kumaphesenti angu-10 kuya kwangu-15 okubuyekezwa kwe-hip esikhundleni) kuyahlakazeka, ngokuvamile ngamandla aphansi aphansi: - I-Posterior Approach THA Dislocation (Okuvamile Kakhulu): Kwenzeka lapho isiguli sigobela phambili okhalweni sidlule ama-degree angu-90 (ukuguquguquka kwe-hip ejulile) ngenkathi siwela imilenze yaso (i-adduction) noma sisonta idolo laso ngaphakathi (ukujikeleza kwangaphakathi), njengokwelula isandla ukuze ubophe isicathulo, ukucosha into esihlalweni esiphansi noma ehlalisa phansi. Izingidi zomlenze fushanisiwe, zagotshwa, zahlanganiswa, futhi zazungezisa ngaphakathi. - Indlela yangaphambili ye-THA Dislocation: Kwenzeka lapho isiguli sinweba inqulu yaso emuva kuyilapho sizungeza unyawo lwaso ngaphandle (njengokuhlehla noma ukugingqika embhedeni). Izingidi zomlenze uzungeziswe ngaphandle futhi wathunjwa. - Umehluko Esimweni Esiphuthumayo: Ngenxa yokuthi insimbi yokufakelwa noma ibhola le-ceramic linamaseli amathambo aphilayo aziro noma ukunikezwa kwegazi, i-avascular necrosis (AVN) ayikwazi ukwenzeka ekuguqekeni kwenyonga yenyonga. Kodwa-ke, i-prosthesis ehlukanisiwe isabangela ubuhlungu obukhulu, ingakwazi ukwelula i- **sciatic noma i-femoral nerve **, futhi iba nzima ukunciphisa ivaliwe njengoba i-spasm ye-gluteal ne-thanga yemisipha phakathi namahora, ngakho-ke ukuthuthwa kwe-ambulensi ngokushesha kwe-intravenous sedation kanye nokunciphisa okuvaliwe eMnyangweni Wezimo Eziphuthumayo kusadingeka.

Ukuphathwa kwezimo eziphuthumayo esibhedlela: I-Fascia Iliaca nerve blocks kanye newindi lokuhlinza lamahora angama-24 kuye kwangama-48¶

1. Ukulawula Ubuhlungu Bangaphambi Kokusebenza Ngaphandle Kwe-Opioid Delirium: I-Fascia Iliaca Compartment Block¶

Kubantu abadala asebekhulile abane-hip ephukile, ukunikeza izilinganiso eziphezulu eziphindaphindiwe ze-morphine emithanjeni, i-hydromorphone, noma i-fentanyl eMnyangweni Wezimo Eziphuthumayo ngokuvamile kubangela ** ukudangala okukhulu kwesibhedlela, ukucindezeleka kokuphefumula, isicanucanu, nokugcinwa komchamo **, kuyilapho ishiya inqulu ibuhlungu kakhulu njalo lapho isiguli siyiswa etafuleni le-X-ray noma embhedeni. - I-Modern Gold Standard (AAOS, NICE, & ACEP Guidelines): Ngokushesha ngemva kokuqinisekisa ukuphuka kwenyonga eMnyangweni Wezimo Eziphuthumayo, odokotela bezimo eziphuthumayo noma odokotela ababulala izinzwa benza *I-Fascia Iliaca Compartment Block (FICB) eqondiswa yi-ultrasound noma i-Femoral Nerve / PENG (I-Pericapsular Nerve Act) ivimbela i-rode noma i-roving arpicauch i-bupivacaine). - Phakathi nemizuzu engu-15, i-nerve block yesifunda yenza i-femoral, i-lateral femoral cutaneous, ne-obturator nerve amagatsha ahlinzeka inqulu ephukile, ekhulula amaphesenti angu-80 kuya kwangu-90 obuhlungu bokuphuka amahora angu-12 kuya kwangu-24 ngaphandle kokuvala ubuchopho besiguli noma ukwehlisa izinga lokuphefumula.

2. Kungani Ukuhlinzwa Kwe-Hip Fracture Phakathi Kwamahora angu-24 kuya kwangu-48 Kusindisa Izimpilo¶

Ngokomlando, iziguli esezikhulile ezaphuka inqulu zazihlala zilele embhedeni izinsuku eziningi ngenkathi zinikezwa imvume yokwelashwa isikhathi eside. Izivivinyo zamazwe ngamazwe eziphawulekayo zifakazela ukuthi njalo ukubambezeleka kwamahora angu-24 ngaphezu kwamahora angu-48 ekwenzeni ukuhlinzwa kwe-hip fixation noma i-arthroplasty kukhulisa kakhulu ukufa kwezinsuku ezingu-30 kanye nonyaka ongu-1 ngenxa yezinkinga ezine ezibulalayo zokungakwazi ukubopha umbhede: 1. I-Pulmonary Embolism kanye ne-Deep Vein Thrombosis (DVT) kusuka ku-venous stasis kanye ne-hypercoagulability ebangelwa ukuhlukumezeka. 2. Ukulangazelela okutholwe esibhedlela kanye nenyumoniya ye-hypostatic ngenxa yokungakwazi ukuhlala uqonde nokukhwehlela kakhulu. 3. Izilonda ze-sacral kanye ne-heel pressure (bedsores) ezithelelekile (bedsores) Okuholela ku-*i-sepsis**. 4. I-delirium ebuhlungu kanye nokuchithwa okungenakulungiseka / ukumosheka kwemisipha.

Ngakho-ke, izindinganiso zamazwe ngamazwe zamathambo (NICE CG124 e-UK kanye ne-AAOS e-US) ziphatha ukuphuka kwenyonga ye-geriatric njengento ethi into ebaluleke kakhulu yokuhlinzwa ehlinzwa phakathi kwamahora angu-24 kuya kwangu-36 ngemva kokungena ukuze isiguli sikwazi ukuma futhi sithwale isisindo ngokwelashwa komzimba ngakusasa ekuseni.

3. Ukubuyisela Ukubuyisela Imithi Yegazi (Anticoagulant) Ngaphambi Kokuhlinzwa Kokuphuka Kwe-Hip¶

Uma isiguli sithatha igazi elincane, tshela ithimba labahloli begumbi lezimo eziphuthumayo igama elithi lona kanye nehora iphilisi lokugcina eligwinywe ngalo: - I-Warfarin (Coumadin): Ibuyiselwe emuva ngokushesha nge I-Vitamin K efakwa emthanjeni (\(5\text{ kuya }10\text{ mg}\) IV) kanye ne-4-Factor Prothrombin Complex Concentrate (4F-PCC)* uma ukuhlinzwa okuphuthumayo kudingeka emahoreni, kuqondiswe ku-$\text{INR} <1. - I-Direct Factor Xa Inhibitors (i-Apixaban [Eliquis], i-Rivaroxaban [Xarelto], i-Edoxaban): Amazinga ezidakamizwa acaca ngaphezu kwamahora angu-24 kuya kwangu-36 ngokusebenza kwezinso okuvamile, noma angahlehliswa ekuphumeni kwegazi okusongela ukuphila nge-Andexanet alfa noma 4F-PCC. - I-Direct Thrombin Inhibitor (Dabigatran [Pradaxa]): Ibuyiselwe emuva ngokushesha phakathi namaminithi kusetshenziswa ucezu oluthile lwe-monoclonal antibody Idarucizumab (Praxbind). - I-Tranexamic Acid (TXA, \(1\text{ g}\) IV): Isetshenziswa njalo phakathi nokuhlinzwa ukuphuka kwenyonga ukuze kwehliswe ukulahleka kwegazi kanye nezidingo zokumpontshelwa.

Izinombolo zezimo eziphuthumayo zesifunda kanye nezinqubomgomo ze-ejensi¶

• I-United States ne-Canada: Dayela u-911*. Ngaphansi kokuthi I-American College of Surgeons (ACS) ATLS kanye **neziqondiso ze-*American Academy of Orthopedic Surgeons (AAOS)**, ukugudluka kwenyonga okubuhlungu kuhanjiswa ngokuqondile esikhungweni se-Trauma ukuze kuncishiswe kungakapheli u-\(<6\text{ hours}\), kuyilapho ukuphuka kwenyonga ye-geriatric kungena ithrekhi esheshayo Orthogeriatric Orthopedic Surgeons in the nerve Surgery in2 and nerve Path. amahora angama-48).
• I-United Kingdom: Dayela u-999 (noma 112). Ngaphansi kwe-NICE Clinical Guideline CG124 (Hip Fracture: Management) kanye NeNational Hip Fracture Database (NHFD) Best Practice Tariff, sonke isiguli esiphuka i-hip kufanele sithole i-analgesia ngokushesha (kuhlanganise ne-fascia iliaca nerve block assessment), ijoint orthogeriatrician assessment, nokuhlolwa kwe-orthogeriatrician, usuku lwe-3, nokuhlinzwa ngosuku lwe-3. amahora)**.
• I-European Union: Shayela 112. Landela I-EFORT (I-European Federation of National Associations of Orthopedics and Traumatology) imihlahlandlela yokunakekelwa okushesha ukuphuka kwe-hip kanye nokunciphisa ukugudluka kwe-hip yomdabu ngokushesha.
• I-Australia ne-New Zealand: Dayela u-000* e-Australia noma 111 eNew Zealand. Landela i-Australian and New Zealand Hip Fracture Registry (ANZHFR) Clinical Care Standard (ukuhlolwa kobuhlungu nokuvinjwa kwezinzwa phakathi nemizuzu engama-30 yokufika kwe-ED, ukuhlinzwa phakathi namahora angu-48).
• I-India ne-Asia-Pacific: Dayela u-112 e-India, 119 e-Japan naseNingizimu Korea, noma 995 e-Singapore. Cela i-ambulensi nge i-scoop stretcher noma umatilasi we-vacuum ukuze isiguli sikwazi ukuphakanyiswa phansi siqonde ngaphandle kokugoba noma ukuzungezisa ilunga le-hip elimele.

Bheka izinombolo eziphuthumayo kuzo zonke izinombolo zomhlaba jikelele zokuthunyelwa kwezimo eziphuthumayo.

Imibuzo ejwayelekile ukubuzwa¶

Ngingabona kanjani ngokubheka imilenze yomuntu ngemva kokuwa ukuthi uphuke inqulu noma wagudluka inqulu?¶

Bheka ukuthi idolo nonyawo lomlenze olimele kubheke ngakuphi uma kuqhathaniswa nomlenze omuhle. Cishe kuzo zonke **izinqulu eziphukile (intamo yesifazane noma ukuphuka kwe-intertrochanteric)**, umlenze ubheke ngaphandle, ubukeka ufushane ngamasentimitha angu-2 kuya ku-4, futhi ugoqa ** NGAPHANDLE (uzungeziswe ngaphandle)** ukuze unqenqema lwangaphandle lonyawo luhlale phansi. Ngamaphesenti angu-90 **ama-hips ahlukanisiwe (ukuhlukana kwe-hip posterior)**, inqulu nedolo kuyagoba, kudonseleke phakathi komunye umlenze, futhi kuguqulwe **NGAKAPHAKATHI (kuzungeziswe ngaphakathi)** ukuze idolo nezinzwane zibheke emlenzeni ophambene.

Ingabe umuntu usengaba ne-hip ephukile uma ekwazi ukusukuma aye endlini yangasese ngemva kokuwa?¶

Yebo; cishe amaphesenti angu-5 kuya kwangu-10 okuphuka kwe-hip ** ama-valgus-impact noma ama-non-displaced stress fractures ** lapho ukuphela kwethambo eliphukile kuhlanganiswe ngokuqinile ngaphakathi kwe-capsule ehlangene. Umuntu usengakwazi ukuxhuga izinsuku ezimbalwa futhi angase ezwe ubuhlungu kuphela enqeni noma edolweni langaphakathi. Kodwa-ke, ukuhamba endaweni ethintekile ye-hip fracture kuyingozi kakhulu ngoba ukungahambi kahle okukodwa kungenza iziphetho zethambo zihlukane ngokuphelele, kuklebhule ukunikezwa kwegazi ebholeni le-hip futhi kuguqule inqubo elula yokulungisa isikulufu ibe yindawo egcwele ye-hip.

Kungani ukuphuka kwe-hip kungabangela ubuhlungu emadolweni lapho kungekho lutho olungalungile ngedolo?¶

I- **obturator nerve** kanye ne-**inzwa yesifazane** ithumela amagatsha ezinzwa kukho kokubili i-capsule yangaphakathi yelunga le-hip kanye nesikhumba ne-capsule ehlangene engxenyeni engaphambili engaphakathi yedolo. Ngenxa yokuthi ubuchopho babelana ngalezo zindlela zezintambo zezinzwa, ukucasuka noma ukuphuka ngaphakathi kwe-hip joint kuvame ukuzwakala isiguli kuphela njengobuhlungu obujulile edolweni laso (**ubuhlungu bedolo obubhekiselwe**). Yonke ingane, osemusha (ene-femoral epiphysis eshelelayo), noma umuntu omdala osekhulile onobuhlungu obungachazeki bamadolo ngemva kokushelela kufanele*ihlolwe inqulu futhi ikhishwe nge-X-ray**.

Kungani amahora angu-6 kuwumnqamulajuqu womlingo wokubuyisela inqulu yemvelo egudlukile esokhethini yayo?¶

Lapho ibhola le-hip joint yakho yemvelo (ikhanda lesifazane) likhishwa esikhoxeni salo, imithambo emincane ye-retinacular egijima ikhuphuka intamo yesifazane egcina ithambo liphila iyelulekwa iqine futhi ivalwe. Ucwaningo lwama-Orthopedic lubonisa ukuthi uma i-hip ihlehliswa ngobumnene endaweni ngaphansi kwe-sedation ** phakathi kwamahora angu-6 **, cishe amaphesenti angu-5 kuya kwangu-10 kuphela eziguli ahlakulela ukufa kwamathambo (** i-avascular necrosis, noma i-AVN **); uma inqulu ihlala igudlukile**ngaphezu kwamahora angu-6**, ingozi yokuthi ikhanda lesifazane life futhi liwe phakathi neminyaka engu-2 elandelayo yeqa ngaphezu kwamaphesenti angu-40 kuya kwangu-50.

Kungani abezimo eziphuthumayo bahlole ukuthi ngingakwazi yini ukudonsa uzwane wami omkhulu ngiwuphakamisele ekhaleni lami ngemva kokuphahlazeka kwemoto yami?¶

Ukudonsa uzwane lwakho olukhulu nonyawo phezulu ku-shin yakho (**dorsiflexion**) kulawulwa **ukuhlukaniswa komuntu siqu kwe-nerve sciatic **. Ngenxa yokuthi i-sciatic nerve igijima ngqo ngemuva kodonga olungemuva lwe-hip socket, ukuhlukana kwe-hip yangemuva (kusuka edolweni lakho ukushaya ideshibhodi) kuphahlaza ikhanda lesifazane ngqo ku-nerve ye-sciatic ku-10 kumaphesenti angu-20 wezisulu. Ukuhlola ukuthi ungakwazi yini ukuphakamisa uzwane lwakho olukhulu futhi uzwe phezulu konyawo lwakho utshela ithimba lokuhlukumezeka ngokushesha ukuthi i-nerve ye-sciatic ichotshozwa yi-hip ehlukanisiwe.

Lingakanani igazi umuntu angalahlekelwa ngalo ngaphakathi enqulwini ephukile ngaphandle kweconsi elilodwa legazi elibonakala esikhumbeni?¶

Ngenkathi ukuphuka okuphezulu ngaphakathi kwe-capsule ehlangene eqinile (i-intracapsular femoral neck fracture) kunendawo yokopha cishe amamililitha angu-50 kuya kwangu-150 ngaphambi kokuba ingcindezi ye-capsule ikuvimbe, i-*extracapsular fracture** yehla phansi phakathi kwama-trochanters noma i-femur engenhla (**intertrochanteric or fraive fracture*) izingxenye zethanga. Isiguli singalahlekelwa **1.0 kuya ku-2.0 amalitha egazi** ngaphakathi kwethanga laso, cishe amaphesenti angu-30 kuya kwangu-40 yenani legazi lomuntu osekhulile, okudinga ukuqapha okuseduze kwesikhumba esiphaphathekile, ukushaya kwenhliziyo okusheshayo, nokushaqeka kwe-hypovolemic.

Iziqondiso ezihlobene¶

• Ukuqiniswa kokuphuka kwe-pelvic nokulawula ukopha kwangaphakathi
• Amathambo aphukile, ama-fractures, nama-sprains
• Ihlombe eliqhephukile, i-kneecap, nokunganyakazi kwamalunga
• Ukuqashelwa ukushaqeka nokunakekelwa kwezimo eziphuthumayo

Imithombo neziqondiso ezisemthethweni¶

• I-American Academy of Orthopedic Surgeons (AAOS, United States): Ukuphathwa Kwama-Hip Fractures Kubantu Abadala: I-Clinical Practice Guideline Esekelwe Ebufakazini (igunya le-MRI yokuphuka kwemimoya, izithiyo zemizwa yesifunda yangaphambi kokusebenza,isikhathi sokuhlinzwa phakathi kwamahora angu-24 kuya kwangu-48, kanye ne-tranexamic acid/VTE).
• I-National Institute for Health and Care Excellence (NICE, United Kingdom): Ukuphuka Kwe-Hip: Ukuphathwa (I-Clinical Guideline CG124) kanye ne-British Orthopedic Association Standards for Trauma (BOAST): Ukunakekelwa Kwesiguli Esikhulile Noma Esibuthaka Esinokwaphuka.
• IKomidi Lase-American College of Surgeons (ACS, United States) Ikomidi Lokuhlukumezeka: Advanced Trauma Life Support (ATLS) Imanuwali Yesifundo Somfundi (Traumatic Hip Dislocation 6-hour AVN reduction window, sciatic and femoral neurovascular assessment, kanye nokungqubuzana kwama-splints traction ekulimaleni kwe-hip/pelvic).
• I-Australian and New Zealand Hip Fracture Registry (ANZHFR) kanye neKhomishana yase-Australia Yokuphepha Nekhwalithi Ekunakekelweni Kwezempilo: Izinga Lokunakekelwa Kwe-Hip Fracture.
• I-Orthopaedic Trauma Association (OTA): Imihlahlandlela Yokuzilolonga Yomtholampilo Yokuphuka Kwentamo Ye-Femoral Enamandla Amandla kanye Nokukhishwa Kwe-Hip Yomdabu.