Download Femoral Neck Fractures

Lower limb fractures &
Dislocations
Topics
•
•
•
•
•
•
•
Pelvic Fractures.
Hip Dislocations.
Proximal femoral fracture.
Femoral Shaft Fractures.
Fracture tibial plateau.
Tibial shaft Fractures.
Ankle fractures.
Mechanism of fractures
• Lower limb fracture is a result of a high
energy trauma except in elderly people or
diseased bones
• Types of fracture are depend on position of
limb during impaction and magnitude of forces
applied.
Management
• The proper way to treat a patient with high
energy trauma is to look at the patient as
whole, not to injured limb alone!
• So the aim to treat such patient is to save
life first, then save limb, finally to save
function.
• A.B.C.D
Pelvic Fractures
• Pelvic fracture is a high energy trauma, as a
result of car accident, fall.
• Classifications. (Tile)
Type A. Stable
A 1. Fractures of the pelvic not involving
the Ring.
A 2 . Stable, minimally displaced fracture
of the Ring .
• Type B. Rotationally Unstable,Vertically
Stable.
B1. Open Book
B2 . Lateral Compression: Ipsilateral
B3. Lateral Compression: Contra
lateral
• Type C. Rotationally and Vertically
Unstable
C1 . Unilateral
C2 . Bilateral
C3 . Associated with Acetabular
Fracture
MANEGEMENT
• Aggressive treatment.
• Obtain X-Ray: AP pelvic, Inlet, outlet, Ct Scan.
Treatment
• Aggressive treatment . By A.B.C.D.
• Obtain X-Ray: AP pelvic, Inlet ,outlet
Ct Scan.
• Think in systemic approach.
• Specific treatment:
Type A . symptomatic treatment
Type B .ORIF with plates& screws, External
Fix.
Type C. ORIF with plates & screws. Both AP.
Emergency treatment
Protect primary blood clot by early pelvic
splintage and prevention of exessive movement
Fluids, early blood transfusion, early fresh
frozen plasma, platelets, cryoprecipitate
Prevent hypothermia and acidosis
Stop other bleeding sites
Stabilize pelvis
complications
A. Hemorrhage – life threatening
B. Bladder/bowel injuries
C. Neurological damage
D. Obstetrical difficulties
E. Persistent Sacro-iliac joint pain
F. Post –traumatic arthritis of the hip with
acetabular fractures
Acetabular fracture
• Usually it is a result of high- energy trauma.
• The acetabulum is divided into four
segments—an anterior column and wall
(rim) and a posterior column and wall (rim).
Fractures of the acetabulum are classified
based on their involvement of these
structures .
classification Letournel and Judet
Investigation
• AP pelvis.
• Judat views ( Internal Oblique, Obturator
view)
• CT scan .
TREATMENT
• Indications for Nonoperative Treatment
1. Nondisplaced and Minimally Displaced
Fractures.
2. Fractures with Significant Displacement
but in Which the Region of the Joint Involved
Is Judged To Be Unimportant Prognostically
3. Secondary Congruence in Displaced BothColumn Fractures
• Medical Contraindications to Surgery
• Local Soft Tissue Problems, Such as
Infection, Wounds, and Soft Tissue Lesions
from Blunt Trauma.
• Elderly Patients with Osteoporotic Bone in
Whom Open Reduction May Not Be
Feasible.
• Skeletal traction for 4-6 weeks. And then
start physiotherapy in bed.
Operative Treatment
• Indications for Operative Treatment.
1. An acetabular fracture with 2 mm or
more displacement in the dome of the
acetabulum.
2. Any subluxation of the femoral head from
a displaced acetabular fracture noted on any
of the three standard roentgen graphic views
Complications
• posttraumatic arthritis in 17%.
• a vascular necrosis after posterior
dislocation was 7.5%.
• Infections are reported to occur in 1% to 5%
• Sciatic nerve palsies as a result of the initial
injury occur in approximately 10% to 15%.
• Heterotopic ossification (HO) occurs after
most extensile approaches
HIP Dislocations
Mechanism of
Anterior
Dislocation
Extreme abduction with external rotation of hip.
Anterior hip capsule is torn or avulsed.
Femoral head is levered out anteriorly.
Physical Examination: Classical
Appearance
Posterior Dislocation:
Hip flexed, internally
rotated, adducted.
Complication
• Post traumatic arthritis
• Femoral head injury with risk of AVN
(100% if the dislocation last >12 H)
• Sciatic nerve palsy 25% ( 10 % permanent)
• Femoral shaft /neck fracture
• Knee injury
• Garden [1961]
I
Valgus impacted or
incomplete
II Complete
Non-displaced
III Complete
Partial displacement
IV Complete
Full displacement
** Portends risk of AVN and
Nonunion
Garden Classification
І
ІІ
ІІІ
ІV
Classification
• Pauwels [1935]
– Angle describes vertical shear vector
Fracture
Classification in
2006
31
AO / OTA
Uncontrolled factor: Fracture geometry
Stable
Unstable
Uncontrolled factor: Fracture geometry
AO/OTA31A3:
The highly unstable “pertrochanteric” fractures!
Treatment
neck of femur
• Nondisplaced fracture of neck of femur can
be treat with canulated screws.
• Displaced fracture IF in patient less than 60
years.
• > than 65 years look for.
Level of activities.
Status of the acetabulum.
then chose THR vs hemi arthoplasty.
Treatment
• Intertrochantaric fracture-------DHS .
DCP.PFN
• Subtrochantaric fracture--------DHS.DCP.PFN
• Combination of both------- IM Nail with
Srews.
Nonoperative Treatment
• Indicated for nondisplaced fractures
– <2mm of articular stepoff and <3mm of
diastasis with an intact extensor mechanism
• May also be considered for minimally
displaced fractures in the elderly
• Patients with a extensive medical
comorbidities
Nonoperative Treatment
• Long leg cylinder cast for 4-6 weeks
– May consider a knee immobilizer for the
elderly
• Immediate weightbearing as tolerated
• Rehabilitation includes range of motion
exercises with gradual quadriceps
strengthening
Operative Treatment
• Goals
– Preserve extensor function
– Restore articular
congruency
• Preoperative Setup
– Tourniquet
• Prior to inflation, gently
flex the knee
• Approach
– Longitudinal midline
incision recommended
– Transverse approach
alternative
– Consider future surgeries!
Operative Techniques
•
•
•
•
•
Modified tension band wiring
Lag-screw fixation
Cannulated lag-screw with tension band
Partial patellectomy
Patellectomy
Plateau fracture
Schatzker 1:
Split Fracture of the lateral side.
Schatzker 2:
Lateral split with depression
Schatzker 3:
Pure lateral depression; no splitting
Schatzker 4
.
Medial tibial plateau split or split depression type fracture
Schatzker 5:
Split fractures of both medial and lateral tibial plateaus
Schatzker 6
Split extends to metadiaphysis, separating metaphysis from
diaphysis
Clinical features
•
•
•
•
•
•
Pain
Swelling
Deformity
Haemarthrosis
Decrease movement of knee
Instability in valgus or varus
Schatzker I:
• Definition:. Lateral split
• Etiology: Often due to valgus stress.
Occurs in younger patients with
stronger bones, which are resistant to
depression. Often due to a bumper
injury.
• Common associated injuries:
Lateral meniscal tear. The lateral
meniscus may also become entrapped
in the fracture and require
arthroscopy.
• Treatment: Typically, lateral
fixation.
Schatzker II
• Most common tibial plateau fracture.
• Definition: Lateral split with depression.
• Etiology: Often due to valgus or axial
stress. Occurs in older patients with
osteoporosis with bones that do not resist
depression.
• Common associated injuries: Lateral
meniscus, medial meniscus, and medial
collateral ligament.
• Treatment: Typically, lateral fixation.
The depressed fragments are elevated and
supported with bone graft.
Schatzker III:
• Definition: Pure lateral depression; no
splitting
• Etiology: Older patients with
osteoporosis. Often just due to a fall.
• Common associated injuries: If the
depressed fragments are lateral and
posterior, it is associated with joint
instability.
• Treatment: If there is instability, the
fractured fragments are elevated and
supported with bone graft and lateral
internal fixation.
Schatzker IV:
• Definition: Medial tibial plateau fracture
that may be a split or split depression type
fracture.
• Etiology: Varus stress. Often severe
trauma.
• Common associated injuries: Associated
with avulsion of the intercondylar
eminence, which may indicate anterior
cruciate ligament injury. Lateral collateral
ligament injury. Peroneal nerve injury.
Popliteal artery injury.
• Treatment: Medial plate and screws.
Schatzker V:
• Definition: Split medial and
lateral tibial plateau
(Bicondylar). Metaphysis is still
in continuity with the diaphysis.
• Etiology: Often pure axial stress
with severe trauma.
• Common associated injuries:
Neurovascular, ACL, and
meniscal injuries.
• Treatment: Typically, medial
and lateral internal fixation.
Schatzker VI:
• Definition: Metaphyseal fracture
that separates the articular surface
from the diaphysis.
• Etiology: High-energy trauma.
• Common associated injuries:
Neurovascular injury and
compartment syndrome. Also
meniscal, ACL, and collateral
ligament injuries.
• Treatment: Typically medial and
lateral internal fixation
Treatment
In plateau fracture
Undisplaced fractures : - above knee , POP cast
with 5 degree flexion or cast bracing
Displaced fractures : - closed reduction , with or
without skeletal tractionand a long leg cast
In depressed fractures : • For less than 8 mm depression (above knee casts )
• For more than 8 mm with a large splint fragment,
skeletal traction
• For more than 8 mm with a smaller splint fragment
(ORIF with bone grafting after elevation of the
depression )
M
a
l
u
n
i
o
n
o
r
n
o
n
u
n
i
o
n
:
T
h
i
s
COMPLICATIONS
•
•
•
•
•
•
•
•
Knee stiffness
Infection
Compartment syndrome
Malunion or nonunion
Posttraumatic osteoarthritis
Peroneal nerve injury
Popliteal artery laceration.
Avascular necrosis
Distal tibia fractures
PILON FRACTURES
( TIBIAL PLAFOND FRACTURES )
- Due to axial loading forces following the
RTA or fall from height
- Males are more commonly affected than
females
- Mean age is 35 to 40 years
Classification
• Type 1 : - undisplaced cleavage fracture of the
joint and are usually low energy injuries in which
the fracture fragments are nearly aligned
• Type 2 : - displaced but minimally comminuted
fractures and are usually moderate energy injuries
• Type 3 : - highly comminuted and displaced
fractures and are usually high energy injuries
Type 1 : - undisplaced cleavage
fracture of the joint and are usually
low energy injuries in which the
fracture fragments are nearly aligned
Type 2 : - displaced but minimally
comminuted fractures and are
usually moderate energy injuries
Type 3 : - highly comminuted and
displaced fractures and are
usually high energy injuries
Clinical features
•
•
•
•
•
Pain
Swelling
Deformity
Inability to bear weight
Loss of sensation
Findings
• Look for peripheral pulses and the sensation in the
foot
• Look for deformity and swelling
• Look for local bruising , fracture blisters and if
there is a tense calf muscles (indicates
compartmental syndrome)
• Investigations
• X – rays AP , lateral and ankle mortise view
• CT scan (nature and extent of the injury)
Treatment
Minimally displaced fractures :treated with a plaster cast on external
fixator
Displaced fractures : open reduction and internal fixation with
plate and screws
Complications include
• infection
• mal-union or union of the fracture in a
unacceptable position
• non-union that is failure of the fracture to
unite
• arthritis of the ankle joint
Thank you