Common lower limb fracture

COMMON LOWER LIMB FRACTURE

Dr Tarif AlakhrasOrthopedic surgeon

kfmc

Common lower limb fracture

• Fracture of the proximal femur (hip fracture) • Fracture of the shaft of the femur • Fracture of the distal femur• Fracture of the proximal tibia• Fracture the shaft of the tibia• Ankle fractures

Blood Supply to Femoral Head

Artery of Ligamentum Teres• Most important in children.• Its contribution decreases with

age, and is probably insignificant in elderly patients.

Ascending Cervical Branches.•formed by branches of medial and

lateral circumflex femoral arteries.•Penetrate capsule near its femoral

attachment and Highly susceptible to injury with hip dislocation.

Hip fracture

Intracapsular v extracapsular• The capsule envelopes the

femoral head and neck• Intertrochanteric and

subtrochanteric fractures do not involve the neck of femur

Hip fracture

Capsule Area

Intracapsular

femoral head

femoral neck

Subcabital

Transcervical

Basicervical

ExtracapsularIntrtrochanteric

subtrochanteric

Femoral Head Fractures

• A rare fracture pattern.• requires high amounts

of energy.• The classic mechanism

of injury for femoral head fracture is traumatic posterior dislocation of the hip

Femoral Head Fractures

• Examination of the injured hip often reveal hip pain & shortened lower extremity

• neurologic examination is important to rule out sciatic nerve injury

• an ipsilateral knee examination is also required with attention paid to ligamentous stability (dashboard injury)

Femoral Head Fractures

The CT scan is not only important for assessing the femoral head fracture pattern (size, location, comminution), but also to evaluate the congruity of the hip joint and determine the presence or absence of intra-articular loose fragments.

Femoral Head Fractures

Treatment• Fracture-dislocation of the hip is a true

orthopaedic emergency.• The goals of definitive treatment of femoral

head fractures are to achieve an anatomic reduction, achieve and maintain joint stability, and remove any interposed bone fragments. decision-making process.

Femoral Head Fractures

Nonoperative treatment• closed reduction and skeletal traction if close reduction is possible and the hip

joint is stable for fracture with less than 1 mm of displacement on CT scan.

Operative treatment• The indications for surgical management

include nonanatomic reduction of the femoral head articular surface, an unstable hip joint, and the presence of intra-articular incarcerated fragments that are preventing a congruent joint reduction

Femoral Neck Fractures• These injuries occur in 2

distinct populations, (1) young, active individuals (2) elderly individuals with

osteoporosis• It is more common in the

elderly and female.• Whites > blacks

Femoral Neck Fractures

Mechanism of injury:• Elderly osteoporotic people :simple fall, with

twisting the hip into external rotation.• young, active individuals: usually caused by a

high-energy impact (fall from height or RTA).• Stress fracture of the femoral neck occur in

runner or military personnel.

Femoral Neck Fractures

• Presentation• Hip pain may radiate to

the knee. • inability to bear weight.• The affected leg may be

shortened, adducted and externally rotated.

• Pain over the hip may be particularly aggravated by rotation of the leg.

Femoral Neck Fractures

• Garden classification - Simulation

• I - Incomplete or impacted bone injury

• II - Complete (across whole neck) - undisplaced

• III - Complete - partially displaced

• IV - Complete - totally displaced

Femoral Neck Fractures• Surgery should be performed on the day of, or the day

after, admission.• Internal fixation with screws if undisplaced• displaced intracapsular fractures may be treated

either by reduction and internal fixation in younger fit patient<50 years, or by replacement of the femoral head in older less fit patients.

• Internal fixation is associated with less initial operative trauma but has an increased risk of reoperation on the hip.

Femoral Neck Fractures

Femoral Neck Fractures

Complications• Nonunion– 5% of non-displaced– 25% of displaced

fractures

• Osteonecrosis– 0% of non-displaced– 27% of displaced

fractures

Intertrochanteric fractures• trochanteric hip fracture

occurs between the greater trochanter, where the gluteus medius and the gluteus minimus (hip abductors) attach, and the lesser trochanter, where the iliopsoas (hip flexor) attaches

Intertrochanteric fractures• Frequency• Among individuals older than 60 years,

intertrochanteric fractures occur more than twice as often in women as in men.

elderly, osteoporotic women• In the age group between 11 and 60 years,

however, males sustain more fractures than females. Due to high-energy trauma

Intertrochanteric fractures

• Etiology Increased bone fragility of the intertroch areafrom osteoporosis and osteomalacia secondary to a

lack of adequate ambulation or antigravity activities, as well as decreased hormone levels, decreased intake of calcium or vitamin D, and other aging processes.

Benign and malignant tumors, along with metastases such as multiple myeloma and other malignancies, can also lead to weakened bony structure.

Intertrochanteric fractures

• Clinical evaluation– Inability to bear-weight– Limb is short, abducted and

externally rotated

• Radiological evaluation– AP ,Lateral ,pelvic ,chest– Joint above and joint below

should be included

Intertrochanteric fracturesCoexisting or preexisting conditions • Pulmonary insufficiency• Cardiac insufficiency• Cardiovascular insufficiency• Hypertension• Dehydration & Malnutrition• metabolic diseases or endocrine diseases, (diabetes and

hypothyroidism)• A younger patient with a high-energy fracture has the

potential for multiple other injuries to the remainder of the body, especially the head, chest and abdomen.

Intertrochanteric fractures• Current treatment of intertrochanteric

fractures is surgical intervention.

• Proximal femoral nail Dynamic hip screw (DHS)

Intertrochanteric fracturesnonsurgical management accompanied by unacceptable morbidity and mortality

because of frequent complications associated with prolonged immobilization or inactivity.

Such complications included the following:• Pulmonary embolism (PE) from deep vein

thrombosis(DVT)• Pressure ulcers • Joints stiffness and muscle atrophy• Malunion, the fracture heals with unacceptable

shortening, rotation, or angulation of the extremity

Femoral shaft fractures

• High mechanism of energy• Inability to bear weight• AP & lateral radiographs Two joints veiw

• Bleeding:– Can easily loose 2L of blood

• Risk of thromboembolism

Femoral shaft fractures

• Treatment : always surgical intramedullary nail is the best. Platting is another option

Distal Femur Fractures

• Defined as fxs from articular surface to 5cm above metaphyseal flare

Supracondylar or intercondylar• Mechanism– young patients

• high energy with significant displacement

– older patients• low energy in osteoporotic bone

with less displacement

Distal Femur Fractures

potential for injury to popliteal artery if significant displacement if no pulse after gross alignment restored then angiography is indicated

Distal Femur Fractures• Radiographs

– obtain standard AP and Lat• AP, Lat

• CT– obtain with frontal and sagittal reconstructions– useful for

• establish intra-articular involvement• identify separate osteochondral fragments in the area of the

intercondylar notch• preoperative planning

• Angiography– indicated when diminished distal pulses after gross alignment

restored

Distal Femur Fractures

Treatment• Nonoperative

– knee brace with NWB for 6 weeks• indications (rare)

– nondisplaced fractures– nonambulatory patient– patient with significant comorbidities

• Operative– open reduction internal fixation

• indications– displaced fracture– intra-articular fracture– nonunion

Tibia and Fibula Fracture

Mechanism of injury• Direct forces such as

those caused by falls and MVCs( transverse frx)

More soft tissues injury

• Indirect or rotational forces (spiral frx)

less injury to the soft tissues

• Most common long bone fracture

• Most common open fracture

Bone immediately under skin

• Significant cost– 569,000 hospital days

(USA)

• Significant complications– Nonunions , compartment

syndrome

Tibial shaft fracture : treatment

Conservative• Shortening <1cm• Angulation in

varus/valgus plane< 5o

• Angulation in antero-posterior plane <10o

• Rotation neutral to slight external rotation

• Bone apposition >50%

Tibial shaft fracture : treatment

• Long leg cast (5 degrees

of flexion) for 4-6 weeks• patella-bearing

cast(Sarmiento) or fracture brace

• The average union time is 16±4 weeks

Tibial shaft fracture : treatment

Surgical treatment• Intramedullary (IM)

Nailing is the best treatment for mid shaft tibia fracture

• The most complication is anterior knee pain!!

Surgical treatmentPlate fixation• 97% success rates • Complication: – infection,– wound breakdown,– nonunion

• i

Tibial plateau fractures• Occur from axial loading with

valgus or varus forces, such as in a fall from a height. The lateral tibial plateau is fractured more frequently than the medial plateau.

• Presented by knee effusion • lead to early OA in the knee joint.• Treated conservatively or surgically

depending on the degree of displacement & joint surface disruption.

Ankle fracture

Together, the distal tibia and fibula form a concave mortis in which the talus is firmly held by the medial (deltoid) and lateral collateral lig.

Ankle fracture

• Neer pointed out that the tibia, fibula, talus and connecting ligaments form a closed circle similar to the pelvic. Interruption at one side is usually associated with remote injury

Ankle fracture • Most ankle fractures are

isolated malleolar fractures. • Medial malleolus • Lateral malleolus• Posterior malleolus

• Mechanism of injury: position of the foot at time of injury, the magnitude, direction, and rate of loading

Ankle fracture

Evaluation- Common symptoms for a

broken ankle include:• Immediate and severe pain• Swelling & Bruising• Tender to touch• Cannot put any weight on

the injured foot• Deformity

Ankle fracture

• Radiographic– AP & Lateral– Mortise views

Foot in 15o of internal rotation

Ankle fracture

Ankle fracture

Denis –Weber classification Based on fibular fracture:– A. Infra-syndesmotic– B. Trans-syndesmotic – C. Supra-syndesmotic:• usually syndesmosis is torn

Ankle fracture

Denis –Weber classification Bimalleolar feactur

Maisonneuve fracture.

Ankle fracture

• Undisplaced:– Below knee cast (NWB)

• Indications for ORIF– All fracture-dislocations– All type C fractures– Tri-malleolar fractures– Talar shift or tilt– Failure to achieve or/maintain closed reduction

Ankle fracture

Syndesmotic injury With out syndesmotic injury