Download MBBS (Bachelor of Medicine, Bachelor of Surgery) Orthopaedics PPT 11 Lower Extremity Trauma Lecture Notes
Lower Extremity Trauma
Hip Fractures / Dislocations
Femur Fractures
Patel a Fractures
Knee Dislocations
Tibia Fractures
Ankle Fractures
Hip Fractures
Hip Dislocations
Femoral Head Fractures
Femoral Neck Fractures
Intertrochanteric Fractures
Subtrochanteric Fractures
Epidemiology
250,000 Hip fractures annual y
Expected to double by 2050
At risk populations
Elderly: poor balance & vision, osteoporosis,
inactivity, medications, malnutrition
Young: high energy trauma
Hip Dislocations
Significant trauma, usual y MVA
Posterior: Hip flexion, Hip Internal y
Rotated & Adducted
Anterior: Limb in Flexion, External
Rotation, Abduction
Hip Dislocations
Emergent Treatment: Closed Reduction
Dislocated hip is an emergency
Goal is to reduce risk of Avascular Necrosis and
Degenrative Joint Disease
Al ows restoration of flow through occluded or
compressed vessels
Literature supports decreased AVN with earlier
reduction
Requires proper anesthesia
Requires "team" (i.e. more than one person)
Hip Dislocations
Emergent Treatment: Closed Reduction
General anesthesia with muscle relaxation facilitates
reduction, but is not necessary
Conscious sedation is acceptable
Attempts at reduction with inadequate analgesia/
sedation wil cause unnecessary pain, cause muscle
spasm, and make subsequent attempts at reduction
more difficult
Hip Dislocations
Emergent Treatment: Closed
Reduction
Insert
hip
Reduction Picture
Al is Maneuver
Assistant stabilizes pelvis with
pressure on Ant. Sup. Iliac
Spine
Surgeon stands on stretcher
and gently flexes hip to 90deg,
applies progressively
increasing traction to the
extremity with gentle
adduction and internal rotation
Reduction can often be seen
and felt
Hip Dislocations
Fol owing Closed Reduction
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
for emergent OR trip to remove incarcerated fragment of
bone)
Femoral Head Fractures
Concurrent with hip dislocation due to shear
injury
Femoral Head Fractures
Pipkin Classification
I: Fracture inferior to fovea
II: Fracture superior to fovea
II : Femoral head + acetabulum fracture
IV: Femoral head + femoral neck fracture
Femoral Head Fractures
Treatment Options
Type I
Nonoperative: non-displaced
ORIF if displaced
Type II: ORIF
Type II : ORIF of both fractures
Type IV: ORIF vs. hemiarthroplasty
Femoral Neck Fractures
Garden Classification
I Valgus impacted
II Non-displaced
III Complete: Partial y
Displaced
I
II
IV Complete: Ful y
Displaced
Functional
Classification
Stable (I/I )
Unstable (III/IV)
III
IV
Femoral Neck Fractures
Treatment Options
Non-operative
Very limited role
Activity modification
Skeletal traction
Operative
ORIF
Hemiarthroplasty (Endoprosthesis)
Total Hip Replacement
Hemi
ORIF
THR
Femoral Neck Fractures
Young Patients
Urgent ORIF (<6hrs)
Elderly Patients
ORIF possible (higher risk AVN, non-union, and
failure of fixation)
Hemiarthroplasty
Total Hip Replacement
Intertrochanteric Hip Fx
Intertrochanteric
Femur Fracture
Extra-capsular femoral
neck
To inferior border of
the lesser trochanter
Intertrochanteric Hip Fx
Intertrochanteric Femur
Fracture
Physical Findings: Shortened
/ ER Posture
Obtain Xrays: AP Pelvis,
Cross table lateral
Intertrochanteric Hip Fx
Classification
# of parts: Head/Neck, GT, LT, Shaft
Stable
Resists medial & compressive Loads after fixation
Unstable
Col apses into varus or shaft medializes despite anatomic
reduction with fixation
Reverse Obliquity
Intertrochanteric Hip Fx
Stable
Unstable
Reverse
Obliquity
Intertrochanteric Hip Fx
Treatment Options
Stable: Dynamic Hip Screw (2-hole)
Unstable/Reverse: Intra Medul ary Recon Nail
Subtrochanteric Femur Fx
Classification
Located from LT to 5cm
distal into shaft
Intact Piriformis Fossa?
Treatment
IM Nail
Cephalomedul ary IM Nail
ORIF
Femoral Shaft Fx
Type 0 - No comminution
Type 1 - Insignificant butterfly
fragment with transverse or short
oblique fracture
Type 2 - Large butterfly of less than
50% of the bony width, > 50% of
cortex intact
Type 3 - Larger butterfly leaving less
than 50% of the cortex in contact
Type 4 - Segmental comminution
Winquist and Hansen 66A,
1984
Femoral Shaft Fx
Treatment Options
IM Nail with locking screws
ORIF with plate/screw construct
External fixation
Consider traction pin if prolonged delay to surgery
Distal Femur Fractures
Distal Metaphyseal Fractures
Look for intra-articular
involvement
Plain films
CT
Distal Femur Fractures
Treatment:
Retrograde IM Nail
ORIF open vs. MIPO
Above depends on
fracture type, bone
quality, and fracture
location
Knee Dislocations
High association of injuries
Ligamentous Injury
ACL, PCL, Posterolateral Corner
LCL, MCL
Vascular Injury
Intimal tear vs. Disruption
Obtain ABI's (+) Arteriogram
Vascular surgery consult with repair
within 8hrs
Peroneal >> Tibial N. injury
Patella Fractures
History
MVA, fal onto knee, eccentric
loading
Physical Exam
Ability to perform straight leg
raise against gravity (ie, extensor
mechanism stil intact?)
Pain, swel ing, contusions,
lacerations and/or abrasions at the
site of injury
Palpable defect
Patella Fractures
Radiographs
AP/Lateral/Sunrise views
Treatment
ORIF if ext mechanism is
incompetent
Non-operative treatment with
brace if ext mechanism remains
intact
Tibia Fractures
Proximal Tibia Fractures (Tibial Plateau)
Tibial Shaft Fractures
Distal Tibia Fractures (Tibial Pilon/Plafond)
Tibial Plateau Fractures
MVA, fal from height, sporting injuries
Mechanism and energy of injury plays a
major role in determining orthopedic care
Examine soft tissues, neurologic exam
(peroneal N.), vascular exam (esp with medial
plateau injuries)
Be aware for compartment syndrome
Check for knee ligamentous instability
Tibial Plateau Fractures
Xrays: AP/Lateral +/- traction films
CT scan (after ex-fix if appropriate)
Schatzker Classification of Plateau Fxs
Lower Energy
Higher Energy
Tibial Plateau Fractures
Treatment
Insert blister
Pics of ex-fix here
Spanning External
Fixator may be
appropriate for
temporary stabilization
and to al ow for
resolution of soft tissue
injuries
Tibial Plateau Fractures
Treatment
Definitive ORIF for patients
with varus/valgus instability,
>5mm articular stepoff
Non-operative in non-
displaced stable fractures or
patients with poor surgical
risks
Tibial Shaft Fractures
Mechanism of Injury
Can occur in lower energy, torsion type injury (e.g.,
ski ng)
More common with higher energy direct force (e.g.,
car bumper)
Open fractures of the tibia are more common than
in any other long bone
Tibial Shaft Fractures
Open Tibia Fx
Priorities
? ABC'S
? Associated Injuries
? Tetanus
? Antibiotics
? Fixation
Tibial Shaft Fractures
Management of Open Fx
Soft Tissues
ER: initial evaluation
wound covered with sterile
dressing and leg splinted,
tetanus prophylaxis and
appropriate antibiotics
OR: Thorough I&D
undertaken within 6 hours
with serial debridements as
warranted fol owed by
definitive soft tissue cover
Tibial Shaft Fractures
Definitive Soft Tissue Coverage
? Proximal third tibia fractures can be covered with
gastrocnemius rotation flap
? Middle third tibia fractures can be covered with
soleus rotation flap
? Distal third fractures usual y require free flap for
coverage
Tibial Shaft Fractures
Treatment Options
IM Nail
ORIF with Plates
External Fixation
Cast
Tibial Shaft Fractures
Advantages of IM nailing
Lower non-union rate
Smal er incisions
Earlier weightbearing and function
Single surgery
Tibial Shaft Fractures
IM nailing of distal
and proximal fx
Can be done but
requires additional
planning, special nails,
and advanced
techniques
Tibial Pilon Fractures
Fractures involving distal tibia metaphysis and
into the ankle joint
Soft tissue management is key!
Often occurs from fal from height or high energy
injuries in MVA
"Excel ent" results are rare, "Fair to Good" is the
norm outcome
Multiple potential complications
Tibial Pilon Fractures
Initial Evaluation
Plain films, CT scan
Spanning External Fixator
Delayed Definitive Care to protect soft tissues and
al ow for soft tissue swel ing to resolve
Tibial Pilon Fractures
Treatment Goals
Restore Articular Surface
Minimize Soft Tissue Injury
Establish Length
Avoid Varus Col apse
Treatment Options
IM nail with limited ORIF
ORIF
External Fixator
Tibial Pilon Fractures
Complications
Mal or Non-union (Varus)
Soft Tissue Complications
Infection
Potential Amputation
This post was last modified on 07 April 2022