Orthopedics - lower limb

Femoral neck fracture( complications)

- 1st year mortality rises to 14%-50%, from increasing risk like: medical comorbidities, surgical delay > 3 days, Institutionalized / demented patient, posterior approach to hip, post-traumatic arthrosis, joint penetration with hardware, AVN related - Non- union of the fracture site (20%) - Osteonecrosis (36%) - Dislocation - Failure of treatment

general feature of PFN (intertrochanteric fracture)

- 24 cm long - distal part: has dynamic o static locking holes - enter pyriformis fossa - indication: curved femur

imagistic (ankle fractures)

- AP - lateral-malleolar frac: Tib\fib> 10 mm

management (femoral shaft fractures)

- ATLS resuscitation - regional analgesia - X-ray - Femoral nerve block - Traction splint - hip fracture surgery within 48 h - intense physical therapy after hospital admi. - vitamin D + calcium supplemnets for pat following hip fracture

methods of non operative treatment (intertrochanteric fracture)

- Buck´s traction (if very old) - Plaster/Hip spica - Skeletal traction through distal femur or tibia for 10-12 weeks with Bohler-Braun splint

clinical pic (intertrochanteric fracture)

- Elderly pat w history of a fall and instability to walk - inspection: Flexion, adduction and external rotation, shortening of leg palpation: tenderness over anterior and lateral aspects of hip joint - all movement are painful expect in rare cases of impacted type of fracture

operative treatment (intertrochanteric fracture)

- Internal fixation (Intermedullary nail (gama nail) or dynamic hip screw (DHS)) in order to obtain best possible position and early ambulation to reduce complication w prolonged recumbency

Surgical Indications depending on fracture Characteristics (Tibia (Shinbone) Shaft Fractures)

- Meta-Diaphyseal location - Oblique fracture pattern - Coronal Angulation > 5° - Sagittal Angulation > 10° - Rotation > 5° - Shortening > 1cm - Comminution > 50% cortical circumference - Intact fibula

Femoral neck fracture( treatment options)

- Non-surgical have a Limited role: - usually high operative risk patient - valgus impacted fracture - elderly patient with comorbidities - mobilize early - Surgical options: - reduction and fixation - open or percutaneous - cancellous screwed, sliding hip screw

Surgical Indications depending on patient characteristics (Tibia (Shinbone) Shaft Fractures)

- Obese - Poor compliance with non-operative management - Need for early mobility

symptoms (ankle fracture)

- Pain: extend from the foot to the knee. - Swelling: along the length of the leg or be localized at the ankle. - Blisters - Bruises - Decreased ability to walk - Bones protruding through the skin. (open ankle fracture)

early treatment (tibial fractures)

- RICE ?

Femoral neck fracture( treatment principle)

- Spare femoral head - Avoid deformity - improves union rate - optimal functional outcome - Minimize vascular injury

evaluation (femoral shaft fractures)

- X-ray - CT

medications for pain management (femoral shaft fractures)

- acetaminophen - NSAIDs - Gabapentinoids - muscle relaxants - opoids - topical pain medications

complications (femoral shaft fractures)

- acute compartment syndrome - bone infection - injuries to ligaments around the knee

recovery (Tibia (Shinbone) Shaft Fractures)

- against pain: include acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), gabapentinoids, muscle relaxants, opioids, and topical pain medications. - AB - weightbearing - physical therapy and bla bla - anticoagulant - bla bla

clinical evaluation of femoral shaft fracture

- anamnesis: fall trauma - pat is non-ambulatory w pain - variable gross deformity of thigh - swelling - shortening of affected extremity - neurovascular examination

causes (Ankle fractures)

- ankle twisting inward or outward - Rolling your ankle - Tripping or falling - Impact during a car accident unimalleolar fractures: 60 to 70 percent bimalleolar fractures: 15 to 20 percent trimalleolar fractures: 7 to 12 percent

causes (tibial fractures)

- axial compressive forces alone or combined with varus or valgus stress on knee joint - stress - comprimised bone (cancer, infection) - trauma

complications from surgery (femoral shaft fractures)

- blood loss - problems related to anesthesia - infection - injury to nerves and blood vessels - blood clots - fat embolism - malalignment or inability to correctly position broken bone fragments - Hardware irritation

Internal fixation (Tibial Plateau Fractures)

- bone fragments are first repositioned (reduced) into their normal position. - held together with an intramedullary rod or plates and screws

mechanism (distal femural fractures)

- direct trauma of the leg associated w automobile accident - high-impact energy trauma - fall from height

Femoral neck fracture( clinical features)

- elderly w/ Hx of falling - inspection: injured leg in position of *flexion, abduction and external rotation* + *shortening of leg* (displaced fracture) - attachment of capsule to distal fragments prevent excessive external rotation - palpation: tenderness over anterior and lateral aspects of hip joint - greater trochanter is elevated on the injured side - all movements are extremely painful except in rare case of impacted type of fracture

associated disease (distal femural fractures)

- extraarticular component - intraairticular component: can result in joint irregularities -> degenerative joint disease - extensive soft tissue injuries compartment syndrome - rare - associated *meniscal or ligamentous damage* following distal femoral fractures - neuromuscular damage (rare)

treatment of non-displaced fracture (Tibial Plateau Fractures)

- heal w 3-4 months - non surgical treatment - knee brace - physical therapy - rehabilitation

Failure rates( femoral neck fractures)

- high early failure rates in fixation group, which stabilizes after 2 years - 2-year follow-up (elderly population >70 years) with displaced femoral neck fractures - 46% with fixation techniques - 8% with arthroplasty techniques - 2-to-10 year follow-up - failure rate approx. 2-4%, respectively overall failure rates still higher in fixation vs. arthoplasty at 10-year follow-up

causes in young people (distal femural fractures)

- high velocity trauma -> hyperabduction -> adduction -> hyperextension -> axial loading - fall from height

how does tibial fracture differ from a young and a elderly pat?

- in young people -> fragments are are larger and wedged shaped due to shear forces involved and often due to high energy trauma - in elderly -> pure depression fractures are common due to lower energy trauma

complication of surgery (femoral shaft fractures)

- infection - injury to nerves + vessels - blood clots - fat embolism (also due fracture) - malalignment or inability to correct position of broken bone fragments - delayed union or non-union - hardware irritation (irritation from nails or screws) - acute compartment syndrome - open fractures

complications (distal femural fractures)

- infection -> AB - stiffness - knee arthritis: if fracture enter knee joint -> heal w defect in normally smooth surface of joint -> damage protective articular cartilage and the joint surface may sometimes wear down to bare bone

advantage of PFN (intertrochanteric fracture)

- inserted quickly - less blood loss - early ambulation - sliding and limb shortening is less - more successful in reverse oblique fractures

surgical treatment (femoral shaft fractures)

- intramedullary nail through integrate/retrograde insertion: for diaphysial fracture - Plate/ or intramedullary nail depend on location and morphology: for proximal or distal 1/3 fracture - External fixation

indications for Retrograde intramedullary nail (femoral shaft fractures)

- ipsilateral femoral neck fracture - floating knee (ipsilateral tibial shaftfracture) - ipsilateral acetabular fracture - multiple system trauma - bilateral femur fractures - avoid repositioning??? - morbid obesity

associated injuries (femoral shaft fracture)

- ipsilateral femur neck, intertroch, distal femur fracture - patella, tibia, acetubular, pelvic ring fractures - soft tissue injuries of knee - thoracic and abd injuries

ORIF indication of ... if I knew I would tell you (femoral shaft fractures)

- ipsilateral neck fracture require -> screw fixation - fracture at distal metaphyseal -diaphyseal junction - inability to access medullary canal outcomes inferior to IM nailing due to - infection - nonunion - hardware failure

sign, symptoms and PE (distal femural fractures)

- knee pain - tenderness, swelling - bruising - deformity "knee out of place" - leg may appear shorter and crooked - hemarthrosis - supracondylar fractures - reduced range of motion of knee - difficult waking - may be protrusion of bone

indication of external fixation (femoral shaft fractures)

- multiply injured patient - complex distal femur fracture - dirty open fracture - Vascular nailing

knee brace used when (distal femural fractures)

- nondisplaced fractures - nonambulatory patient - patient w significant comorbidities presenting unacceptably high degree of surgical anesthetic risk

anamnesis and PE (Tibia (Shinbone) Shaft Fractures)

- obvious deformity of the tibia/leg - Bruise - Swelling - Bony pieces that may be pushing on the skin - Instability (some patients may retain a degree of stability if the fibula is not broken or if the fracture is incomplete) - check sensation

examination (femoral shaft fractures)

- obvious deformity of thigh/leg - breaks in skin - bruises - bony pieces pushing the skin

Femural neck fracture( definition)

- one of the most common injuries in the elderly (leading to morbidity(can leave them confined to the bed)/mortality) -

sign and symptoms (intertrochanteric fracture)

- pain - shortening of lower limb - pat cant lift the leg .- complete external rotation deformity - swelling, ecchymoses and tenderness of greater trochanter - displaced fracture -> cannot stand - nondisplaced -> ambulatory + minimal pain, complain of thigh/groin pain but no history of antecedent trauma - amount of clinical deformity tells degree of fracture displacement

symtoms (tibial fractures)

- pain (get worse with weightbearing) - swelling around knee - limited joint motion - deformity "knee out of place" - numbness around foot (nerve injury) or "pins and needles" feeling -

postoperative care (distal femural fractures)

- pain management - early motion (passive exercise) - weighbearing (after surgery or not) when fracture is stable - crutches or walker support - X-ray regularly to monitor

postoperative care involve (femoral shaft fractures)

- pain management - AB - weightbearing (early leg motion on recovery period or when fracture has started to heal) - use crutches or walker support - physical therapy (during healing process to restore muscle strength, joint motion, flexibility and pain)

Recovery (tibial plateau fractures)

- pain managment - early and pain free mobilization (passive) - AB prophylaxis - anticoagulants (low molecular weight heparin - 10-15 d) - weight-bearing - partial weight-bearing - crutches or a walker - Further weight-bearing restrictions -> in case of joint depression, - if the patient develops a large hemarthrosis -> arthrocentesis for relief, facilitating joint mobilization and physiotherapeutic rehabilitation

what is acute compartment syndrome

- painful condition and is surgical emergency - occur when pressure within muscles builds to dangerous levels - this pressure decrease blood flow -> prevent nourishment and oxygen from reaching nerves and muscle cells - may lead to permanent disability - to relieve pressure -> incision of skin and muscle coverings

risk factors (distal femural fractures)

- participation in rough, high-impact contact sports - advanced age - reduced bone mass (osteoporosis) - reduced muscle mass - excess body weight assoc with obesity -> increase pressure on joint -

Indications for non surgical treatment (Tibia (Shinbone) Shaft Fractures)

- people that less active, w health probl. - Minimal soft tissue damage - Non-intact fibula Higher rate of nonunion & varus with intact fibula - Stable fracture pattern < 5° varus/valgus < 10° pro/recurvatum < 1 cm shortening - Ability to bear weight in cast or fx brace require: Casting and bracing

Proximal femoral nail (PFN) (intertrochanteric fracture)

- prevent fractures of femoral shaft by having smaller distal shaft diameter which reduces stress conc at the tip - acts as buttress in preventing medialisation of shaft - main priciplet -> sliding screw in femoral neck-head fragment, that is attached to intramedullary nail - preferred in commented unstable trochanteric fractures as it resist demeaning muscle forces

symptoms (Tibia (Shinbone) Shaft Fractures)

- severe pain - Inability to walk or bear weight on the leg - Deformity or instability of the leg - Bone "tenting" over the skin at the fracture site or bone protruding through a break in the skin - Occasional loss of feeling in the foot - Possible loss of feeling in the foot of the affected leg

non surgical treatment (distal femural fractures)

- skeletal traction, casting and bracing: not recommended because they do not allow early knee movement - early mobility -> dec risk of stiffness, DVT and so on

complication (tibial plateau fractures)

- stiffness - knee arthritis - knee instability and loss of motion - If the patient does not recover at least 90° of flexion with 8-10 postoperative wks, arthroscopic release of intra-articular adhesions and knee manipulation under anesthesia are indicated.

AO classification of intertrochanteric fracture

1. A1: Simple (2-fragment) pertrochanteric area fractures 2. A2: Multifragmentary pertrochanteric fractures 3. A3: Intertrochanteric fractures

diagnostic image (intertrochanteric fracture)

1. AP view of pelvis 2. AP and cross table lateral view w proximal femur gives diagnosis

Compartments of thigh

1. anterior: sartorius and 4 large quadriceps 2. medial: gracilas, pectineus, adductor longus, adductor brevis, adductor Magnus, obturator externes 3. posterior: 3 large muscles - hamstrings

recovery (femoral shaft fraterm-67ctures)

3-6 month to completely heal (normally)

Type B (AO classification femoral shaft fractures)

B1: spiral wedge B2: bending wedge B3: fragmented wedge fracture: medium - moderate impacts Spiral fracture: axial loading w torsion or may be caused by falls from height

Garden 4( classification)

Complete femoral neck fracture with full displacement: the proximal fragment is free and lies correctly in the acetabulum so that the trabeculae appear aligned

Garden 2( classification)

Complete fracture without displacement

Garden 3( classification)

Complete with partial displacement: fragments are still connected by posterior retinacular attachment; there is malalignment of the femoral trabeculae

complication (intertrochanteric fracture)

Early: - same as w femoral neck fractures - reflecting the fact that most of these pat are in poor health late: - failed fixation screw -> cut out osteoporotic bone - implant -> break if union is delayed - malunion - Coxa vara and external rotation deformity - non-union - traumatic osteoarthritis - avascular necrosis

Timing of surgery (femoral shaft fractures)

Fixed 24-48 hours fixation delayed until other threatening injuries or unstable medical condition are stabilized put long-leg splint or leg is in traction until surgery

immediate care (ankle fracture)

Gross deformity of the ankle bones Bones visible outside your skin Intolerable pain despite over-the-counter pain medications Inability to move your toes Inability to move your ankle at all Ankle numbness or partial numbness Cold or blue foot

Surgical Indications depending on Injury Characteristics (Tibia (Shinbone) Shaft Fractures)

High Energy Moderate soft-tissue injury Open Fracture Compartment Syndrome Ipsilateral Femur Fx Vascular Injury

Femoral neck impacted physical exam)

Impacted and stress fractures : no obvious clinical deformity minor discomfort with active or passive hip range of motion, muscle spasms at extremes of motion pain with percussion over greater trochanter

Garden 1( classification)

Incomplete fracture of the neck( so-called abducted or impacted)

A3 type( AO intertrochanteric fracture)

Intertrochanteric fractures • A3.1 Simple, oblique • A3.2 Simple, transverse • A3.3 With a medial fragment

surgical methods (Tibia (Shinbone) Shaft Fractures)

Intramedullary Nail ORIF with Plate External Fixation Combination of fixation

associated injuries (Tibia (Shinbone) Shaft Fractures)

Ipsilateral Fibula Fracture Foot & Ankle injury Syndesmotic Injury Ligamentous knee injuries Ipsilateral Femur Fx Neurovascular Injury

causes (Tibia (Shinbone) Shaft Fractures)

Low Energy: - Minimal soft-tissue injury - Less complicated fracture pattern and management decisions - 76.5% closed,53.5% mild soft-tissue energy High Energy: - High incidence of neurovascular injury and open injury - Low threshold for compartment syndrome - Complete soft-tissue injury may not declare itself for several days

A2 type( AO intertrochanteric fracture)

Multifragmentary pertrochanteric fractures • A2.1 With one intermediate fragment (lesser trochanter detachment) • A2.2 With 2 intermediate fragments • A2.3 With more than 2 intermediate fragments

Intertrochanteric fracture( defintion)

Occurs between the greater trochanter (where gluteus Medius and gluteus minimus attach), and lesser trochanter( where iliopsoas attached)

A1 type( AO intertrochanteric fracture)

Simple (2-fragment) pertrochanteric area fractures • A1.1 Fractures along the intertrochanteric line • A1.2 Fractures through the greater trochanter • A1.3 Fractures below the lesser trochanter

imagistic (distal femural fractures)

X- ray CT w 3D: can show if fracture enters joint surface and if so -> how many pieces of bone there are

imagistic (tibial fractures)

X-ray: - AP w\wo traction (if highly communited) - Profile - interna oblique - external oblique CT: - axial slices of knee and reconstruction of image information in coronal and sagittal planes - 3D CT MRI: - not routine - determine injury to the soft tissue - maybe used when X-ray show negative signs of tibial plateau fracture - detect bone marrow reaction -> sign of fracture

Imaging (Tibia (Shinbone) Shaft Fractures)

X-rays: - Full length AP and Lateral Views to Check joint above & below - Oblique views may be helpful in follow-up to assess healing

Intertrochanteric fracture( mechanism)

Younger people: high energy injury such as motor vehicle or great falls Elderly people: simple fall( because they are usually osteoporotic)

difference between splint and cast

a splint can be tightened or loosened to allow swelling to occur safely.

gold standard for diaphysial femur fractures

antegrate intramedullary nail (femoral shaft fractures)

Schatzker classification (I,II, III) (tibial fractures)

associated w low energy mechanism

AO classification is more comprehensive than Schatzker classification - why? (tibial fractures)

because it is universal instead of regional. It includes some types of fractures of the proximal tibia that are not covered by the Schatzker classification, such as extra-articular metaphyseal fractures. In addition, the AO classification allows for grading soft tissue damage, even in closed fractures, leading to a more accurate prognosis

Type C (AO classification femoral shaft fractures)

complex C1: spiral C2: segmental C3: irregular Moderate - severe impacts spiral fracture: axial loading w torsion and may be caused by falls from height

Type B3 ( AO femoral neck fracture)

displaced subcapital fractures - B 3.1 moderately displaced in varus and external rotation - B 3.2 moderately displaced with vertical translation and external rotation - B 3.3 markedly displaced

complication (Tibia (Shinbone) Shaft Fractures)

end of bones are sharp -> cut or tear surrounding muscles, nerves, or blood vessels. Acute compartment syndrome Open fractures expose the bone to the outside environment from surgery: Infection Injury to nerves and blood vessels Blood clots (these may also occur without surgery) Malalignment or the inability to correctly position the broken fragments Delayed union or nonunion (when the fracture heals slower than usual or not at all) Angulation (with treatment by external fixation)

Schatzker classification (IV, V, VI) (tibial fractures)

fracture dislocation of knee and therefore are more severe and associated with significant soft tissue damage

describe fracture of femur shaft

fracture of femoral diaphysis occur between 5 cm distal to lesser trochanter and 5 cm proximal to adductor tubercle

Plates and screws are commonly used for

fractures that enter the joint. If the fracture enters the joint and pushes the bone down, lifting the bone fragments may be required to restore joint function. Lifting these fragments, however, creates a hole in the cancellous bone of the region. This hole must be filled with material to keep the bone from collapsing. This material can be a bone graft from the patient or from a bone bank. Synthetic or naturally occurring products which stimulate bone healing can also be used

Gottfried pertaneous compression plate (advantage) (intertrochanteric fracture)

has ability for pat to attain full weight bearing status immediately postop. this is good for elderly in which early restoration of function is most important its system comprises double axis telescoping neck screw fixation provide rotational stability and it is designed q plate having only 135 degree shaft-neck angle for otimization of imoaction

Dislocation( femoral neck fracture complication)

higher rate of dislocation with THA (~ 10%) about seven times higher than hemiarthroplasty

anamnesis and PE (distal femural fractures)

history: fall from heights inspection: short and externally rotated thigh - quadriceps pull proximal fragment forward - gastrocnemius pulls distal fragement back

Osteonecrosis( femoral neck fracture complication)

incidence of 10-45% recent studies fail to demonstrate association between time to fracture reduction and subsequent AVN increased risk with increase initial displacement AVN can still develop in nondisplaced injuries nonanatomical reduction

Nonunion( femoral neck fracture complication)

incidence of 5 to 30% increased incidence in displaced fractures no correlation between age, gender, and rate of nonunion varus malreduction most closely correlates with failure of fixation after reduction and cannulated screw fixation

intertrochanteric femur

is situated between the extra-capsular femoral neck and the inferior border of the lesser trochanter.

what is LISS (distal femural fractures)

less invasive stabilization system need insertion guide to insert monocortical, self-tapping screws through stab incision A thread in plate provide the angular stability for anchoring of these screws Extra-articular fractures and simple intra-articular fractures, distal femoral nail permits intramedullary stabilization The Forces - transferred from bone to fixator across the screw neck -> thus blood supply of bone under plate is preserved as basically no/little contact between the plate and the bone is needed For stability and sift tissue reasons - internal fixator -> placed very closed to bone - thus the plates are pre-shaped special instruments insertion guide allow the plates to be slid under muscle. Screws are inserted percutaneously via small stab incision

Femural neck fracture( mechanism)

may be result of either from: - rotation violence at the hip due to tripping over something on the floor and falling - a direct violence over the lateral aspect of the hip by a fall on the side

recovery (distal femural fractures)

may take a year or more of rehabilitation (cuz it is a severe injury)

associated injuries (intertrochanteric fracture)

old pat: osteoporosis -> fracture even though it is low-energy fall young pat: high-energy trauma -> possible head, neck, chest and abd injuries

surgical treatment (distal femural fractures)

open fracture -> need cleaning and immediate surgery - delayed 1-3 days to prepare the pat - internal fixation: -> intramedullary nail ->plates and screws - LISS

contraindication of antegrate intramedullary nail (femoral shaft fractures)

pat with closed head injury with critical condition to avoid hypotension and hypoxemia and when it is considered provisional nail fixation

indication of non operative treatment (intertrochanteric fracture)

poor medical and surgical risk pat. terminally ill

non surgical treatment (femoral shaft fractures)

requires surgery very young children are treated with casts long leg cast indication in non-displaced femoral shaft fractures in patients with multiple medical comorbidities for pat in whom surgery need to be delayed -> temporary stabilization w skeletal traction is required

Type A (AO classification femoral shaft fractures)

simple fracture A1: spiral A2: oblique A3: tranverse

Type B1( AO femoral neck fracture)

subcapital fracture no or minimal displacement - B 1.1 impacted in valgus > 15 degrees - B 1.2 impacted in valgus < 15 degrees - B 1.3 nonimpacted

Type B2 ( AO femoral neck fracture)

transcervical - B 2.1 basicervical - B 2.2 midcervical with adduction - B 2.3 midcervical with shear

External fixators (Tibial Plateau Fractures)

used when soft tissue is so poor that the use of a plate or rod might threaten it further The external fixator is removed when the injury has healed.

causes in elderly people (distal femural fractures)

weak bones

indication of antegrate intramedullary nail (femoral shaft fractures)

within 24 hours: - dec pulmonary complications (ARDS) - dec thromboembolic events - improved rehabilitation - dec of hospital stay

mechanism of injury of femoral shaft fracture

young adults -> high energy trauma - motor vechile accident - gunshot injury - fall from heights elderly -> pathologic fracture - trivial fall military recruits or runners -> stress fracture

AO classification of femoral neck fractures

• Type B1 subcapital fracture no or minimal displacement • Type B2 transcervical • Type B3 displaced subcapital fractures

advantages Arthroscopically assisted fixation (tibial plateau fractures)

• better visualization of the articular surfaces and better reduction of the fracture, • better anatomical restoration of the joint surface, • the possibility to assess and treat the associated intra-articular ligamentous and meniscal injuries,to remove loose fragments, • the possibility to achieve stable fixation with the least amount of soft tissues dissection, • low risk of complications and low morbidity • the possibility of converting to arthrotomy, if necessary, • shorter hospital stay with faster recovery of joint motion.