Download MBBS Orthopaedics PPT 11 Lower Extremity Trauma Lecture Notes

Lower Extremity Trauma

Hip Fractures / Dislocations
Femur Fractures

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Patel a Fractures
Knee Dislocations
Tibia Fractures
Ankle Fractures

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Hip Fractures

Hip Dislocations
Femoral Head Fractures
Femoral Neck Fractures

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Intertrochanteric Fractures
Subtrochanteric Fractures
Epidemiology

250,000 Hip fractures annual y

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Expected to double by 2050

At risk populations

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Elderly: poor balance & vision, osteoporosis,

inactivity, medications, malnutrition

Young: high energy trauma

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Hip Dislocations

Significant trauma, usual y MVA
Posterior: Hip flexion, Hip Internal y

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Rotated & Adducted

Anterior: Limb in Flexion, External

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Rotation, Abduction
Hip Dislocations

Emergent Treatment: Closed Reduction

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Dislocated hip is an emergency
Goal is to reduce risk of Avascular Necrosis and

Degenrative Joint Disease

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Al ows restoration of flow through occluded or

compressed vessels

Literature supports decreased AVN with earlier

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reduction

Requires proper anesthesia
Requires "team" (i.e. more than one person)

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Hip Dislocations

Emergent Treatment: Closed Reduction

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General anesthesia with muscle relaxation facilitates

reduction, but is not necessary

Conscious sedation is acceptable

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Attempts at reduction with inadequate analgesia/

sedation wil cause unnecessary pain, cause muscle
spasm, and make subsequent attempts at reduction
more difficult

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Hip Dislocations

Emergent Treatment: Closed

Reduction

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Insert

hip

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Reduction Picture

Al is Maneuver

Assistant stabilizes pelvis with

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pressure on Ant. Sup. Iliac

Spine

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Surgeon stands on stretcher

and gently flexes hip to 90deg,

applies progressively

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increasing traction to the

extremity with gentle

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adduction and internal rotation

Reduction can often be seen

and felt

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Hip Dislocations

Fol owing Closed Reduction

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Check stability of hip to 90deg flexion
Repeat X Ray Pelvis AP
Judet views of pelvis (if acetabulum fx)
CT scan with thin cuts through acetabulum
Remains of bony fragments within hip joint (indication

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for emergent OR trip to remove incarcerated fragment of
bone)
Femoral Head Fractures

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Concurrent with hip dislocation due to shear

injury

Femoral Head Fractures

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Pipkin Classification

I: Fracture inferior to fovea
II: Fracture superior to fovea

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II : Femoral head + acetabulum fracture
IV: Femoral head + femoral neck fracture
Femoral Head Fractures

Treatment Options

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Type I

Nonoperative: non-displaced
ORIF if displaced

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Type II: ORIF
Type II : ORIF of both fractures
Type IV: ORIF vs. hemiarthroplasty

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Femoral Neck Fractures

Garden Classification

I Valgus impacted

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II Non-displaced
III Complete: Partial y

Displaced

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I

II

IV Complete: Ful y

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Displaced

Functional

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Classification

Stable (I/I )
Unstable (III/IV)

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III

IV
Femoral Neck Fractures

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Treatment Options

Non-operative

Very limited role

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Activity modification
Skeletal traction

Operative

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ORIF
Hemiarthroplasty (Endoprosthesis)
Total Hip Replacement

Hemi

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ORIF

THR
Femoral Neck Fractures

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Young Patients

Urgent ORIF (<6hrs)

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Elderly Patients

ORIF possible (higher risk AVN, non-union, and

failure of fixation)

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Hemiarthroplasty
Total Hip Replacement

Intertrochanteric Hip Fx

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Intertrochanteric

Femur Fracture

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Extra-capsular femoral

neck

To inferior border of

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the lesser trochanter
Intertrochanteric Hip Fx

Intertrochanteric Femur

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Fracture

Physical Findings: Shortened

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/ ER Posture

Obtain Xrays: AP Pelvis,

Cross table lateral

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Intertrochanteric Hip Fx

Classification

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# of parts: Head/Neck, GT, LT, Shaft
Stable

Resists medial & compressive Loads after fixation

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Unstable

Col apses into varus or shaft medializes despite anatomic

reduction with fixation

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Reverse Obliquity
Intertrochanteric Hip Fx

Stable

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Unstable

Reverse

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Obliquity

Intertrochanteric Hip Fx

Treatment Options

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Stable: Dynamic Hip Screw (2-hole)
Unstable/Reverse: Intra Medul ary Recon Nail
Subtrochanteric Femur Fx

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Classification

Located from LT to 5cm

distal into shaft

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Intact Piriformis Fossa?

Treatment

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IM Nail
Cephalomedul ary IM Nail
ORIF

Femoral Shaft Fx

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Type 0 - No comminution
Type 1 - Insignificant butterfly

fragment with transverse or short

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oblique fracture

Type 2 - Large butterfly of less than

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50% of the bony width, > 50% of

cortex intact

Type 3 - Larger butterfly leaving less

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than 50% of the cortex in contact

Type 4 - Segmental comminution

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Winquist and Hansen 66A,

1984
Femoral Shaft Fx

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Treatment Options

IM Nail with locking screws
ORIF with plate/screw construct
External fixation

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Consider traction pin if prolonged delay to surgery

Distal Femur Fractures

Distal Metaphyseal Fractures

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Look for intra-articular

involvement

Plain films

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CT
Distal Femur Fractures

Treatment:

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Retrograde IM Nail
ORIF open vs. MIPO
Above depends on

fracture type, bone

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quality, and fracture
location

Knee Dislocations

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High association of injuries

Ligamentous Injury

ACL, PCL, Posterolateral Corner

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LCL, MCL

Vascular Injury

Intimal tear vs. Disruption

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Obtain ABI's (+) Arteriogram
Vascular surgery consult with repair

within 8hrs

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Peroneal >> Tibial N. injury
Patella Fractures

History

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MVA, fal onto knee, eccentric

loading

Physical Exam

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Ability to perform straight leg

raise against gravity (ie, extensor

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mechanism stil intact?)

Pain, swel ing, contusions,

lacerations and/or abrasions at the

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site of injury

Palpable defect

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Patella Fractures

Radiographs

AP/Lateral/Sunrise views

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Treatment

ORIF if ext mechanism is

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incompetent

Non-operative treatment with

brace if ext mechanism remains

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intact
Tibia Fractures

Proximal Tibia Fractures (Tibial Plateau)
Tibial Shaft Fractures

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Distal Tibia Fractures (Tibial Pilon/Plafond)

Tibial Plateau Fractures

MVA, fal from height, sporting injuries

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Mechanism and energy of injury plays a

major role in determining orthopedic care

Examine soft tissues, neurologic exam

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(peroneal N.), vascular exam (esp with medial
plateau injuries)

Be aware for compartment syndrome

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Check for knee ligamentous instability
Tibial Plateau Fractures

Xrays: AP/Lateral +/- traction films
CT scan (after ex-fix if appropriate)

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Schatzker Classification of Plateau Fxs

Lower Energy

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Higher Energy
Tibial Plateau Fractures

Treatment

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Insert blister

Pics of ex-fix here

Spanning External

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Fixator may be
appropriate for
temporary stabilization
and to al ow for

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resolution of soft tissue
injuries

Tibial Plateau Fractures

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Treatment

Definitive ORIF for patients

with varus/valgus instability,

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>5mm articular stepoff

Non-operative in non-

displaced stable fractures or

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patients with poor surgical
risks
Tibial Shaft Fractures

Mechanism of Injury

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Can occur in lower energy, torsion type injury (e.g.,

ski ng)

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More common with higher energy direct force (e.g.,

car bumper)

Open fractures of the tibia are more common than

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in any other long bone

Tibial Shaft Fractures

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Open Tibia Fx
Priorities

? ABC'S

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? Associated Injuries

? Tetanus

? Antibiotics

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? Fixation
Tibial Shaft Fractures

Management of Open Fx

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Soft Tissues

ER: initial evaluation

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wound covered with sterile
dressing and leg splinted,
tetanus prophylaxis and
appropriate antibiotics

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OR: Thorough I&D

undertaken within 6 hours
with serial debridements as
warranted fol owed by

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definitive soft tissue cover

Tibial Shaft Fractures

Definitive Soft Tissue Coverage

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? Proximal third tibia fractures can be covered with

gastrocnemius rotation flap

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? Middle third tibia fractures can be covered with

soleus rotation flap

? Distal third fractures usual y require free flap for

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coverage
Tibial Shaft Fractures

Treatment Options

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IM Nail
ORIF with Plates
External Fixation
Cast

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Tibial Shaft Fractures

Advantages of IM nailing

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Lower non-union rate
Smal er incisions
Earlier weightbearing and function
Single surgery
Tibial Shaft Fractures

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IM nailing of distal

and proximal fx

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Can be done but

requires additional
planning, special nails,
and advanced

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techniques

Tibial Pilon Fractures

Fractures involving distal tibia metaphysis and

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into the ankle joint

Soft tissue management is key!
Often occurs from fal from height or high energy

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injuries in MVA

"Excel ent" results are rare, "Fair to Good" is the

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norm outcome

Multiple potential complications
Tibial Pilon Fractures

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Initial Evaluation

Plain films, CT scan
Spanning External Fixator
Delayed Definitive Care to protect soft tissues and

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al ow for soft tissue swel ing to resolve

Tibial Pilon Fractures

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Treatment Goals

Restore Articular Surface
Minimize Soft Tissue Injury
Establish Length

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Avoid Varus Col apse

Treatment Options

IM nail with limited ORIF

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ORIF
External Fixator
Tibial Pilon Fractures

Complications

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Mal or Non-union (Varus)
Soft Tissue Complications
Infection
Potential Amputation

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