FRACTURES OF THE HIP AND ANKLE James M. Steinberg, D.O. Garden City Hospital

1. FRACTURES OF THE HIP AND ANKLE James M. Steinberg, D.O. Garden City Hospital

2. HIP FRACTURES • More than 250,000 hip fractures in the U.S. each year, expected to double by year 2050 • Falls are the most common cause of fracture in the elderly • High energy trauma is the most common cause in young adults • Femoral head has a very fragile blood supply

3. Femoral Head Fractures • Usually a result of hip dislocations, 10% of posterior hip dislocations • Most are shear or cleavage type fractures • Radiographic evaluation must include an AP and Judet views of the pelvis • Blood supply to the femoral head: -medial femoral circumflex artery (majority) -lateral femoral circumflex -artery of the ligamentum teres

4. Pipkin Classification • Type I: -Hip dislocation with fracture of the femoral head caudad to the fovea capitis femoris • Type II: - Hip Dislocation with fracture of the femoral head cephalad to the fovea capitis femoris

5. Pipkin Classification • Type III: -Type I or II injury associated with fracture of the femoral neck • Type IV: -Type I or II injury associated with fracture of the acetabular rim

6. Treatment of Femoral Head Fractures • Pipkin Type I: -If < 1mm step-off closed treatment, four weeks of traction and four weeks of toe-touch weight bearing -If > 1mm step-off, ORIF with small cancellous screws or herbert screws -In young patients immediate ORIF recommended to allow for early mobilization and prevention of AVN

7. Treatment of Femoral Head Fractures • Pipkin Type II: -For nonoperative care an anatomic reduction must be achieved -ORIF is the treatment of choice utilizing screw fixation

8. Treatment of Femoral Head Fractures • Pipkin Type III: -ORIF of the femoral head followed by screw fixation of the femoral neck -In young patients, emergent ORIF -Prognosis for this fracture is poor and depends on the degree of displacement of the femoral fracture

9. Treatment of Femoral Head Fractures • Pipkin Type IV: -Fracture must be treated in tandem with its associated acetabular fracture -Surgical approach dictated by acetabular fracture -Femoral head should be fixed internally even if nondisplaced

10. Complications of Femoral Head Fractures • AVN • Degenerative arthritis • Sciatic nerve palsy • Heterotopic ossification • Wound infection • Chronic instability

11. Femoral Neck Fractures • Low energy trauma (older patients) : -Fall onto the greater trochanter or forced external rotation of the lower extremity • High energy trauma (younger patients): -MVA or fall from significant height • Cyclical loading/stress fractures (athletes)

12. Evaluation of Femoral Neck Fractures • Physical exam: -Weight bearing status -Shortening and external rotation -Pain with provocative movements • Imaging: -AP in internal rotation and cross-table lateral -MRI if x-rays are negative with a high index of suspicion (first 48 hours) -Bone scan 48 hours after injury

13. Classification of Femoral Neck Fractures • Anatomic: -Subcapital -Transcervical -Basicervical • Pauwel: -Based on angle of fracture from horizontal -Type I: 30 degrees; Type II: 50 degrees; Type III: 70 degrees

14. Garden Classification of Femoral Neck Fractures • Based on degree of valgus displacement -Type I: incomplete/impacted -Type II: complete nondisplaced -Type III: complete with partial displacement (trabecular pattern does not line up) -Type IV: completely displaced (trabecular pattern in a parallel orientation)

15. Treatment of Femoral Neck Fractures • Fatigue/stress fractures: -Tension: in situ screw fixation -Compression: crutch ambulation • Impacted/nondisplaced fractures: -In situ fixation with three cancellous screws except in pathologic fractures, severe OA/RA and Paget’s disease (prosthetic replacement)

16. Treatment of Femoral Neck Fractures • Displaced fractures: ORIF and capsulotomy -25% incidence of AVN within 12 hours -30% within 12-24 hours -40% within 24-48 hours -In young patients, treat as a surgical emergency

17. Operative Techniques of Femoral Neck Fractures • Multiple screw fixation: -Favored technique -Threads should cross the fracture site to allow for compression -Three parallel screws yield the best fixation • Sliding screw devices -Not recommended -If used, second pin should be inserted superiority to control rotation

18. Hemiarthroplasty of Femoral Neck Fractures • Allows for immediate weight bearing • Indications: comminuted fractures, pathologic fractures, nonambulatory status, and neurological conditions • Contraindications: young active patients, active sepsis, and acetabular disease • Bipolar: reduces acetabular erosion (young patients) • Unipolar: less active patients

19. Total Hip Arthroplasty of Femoral Neck Fractures • Indications: -Contralateral hip disease -Ipsilateral acetabular metastatic disease -Preexisting degenerative disease

20. Complications of Femoral Neck Fractures • Nonunion • Osteonecrosis: -10% of nondisplaced fractures -27% of displaced fractures • Fixation failure • Infection • Thromboemboli

21. Intertrochanteric Hip Fractures • Fracture between the greater and lesser trochanters • Extracapsular fracture • Musculature produces shortening, external rotation and varus position at the fracture site: -Abductors displace the greater troch. -Iliopsoas displaces the lesser troch. -Hip flexors, extensors, and adductors pull the shaft proximally

22. Evaluation of Intertrochanteric Hip Fractures • Typically fractures result from a fall, direct blow to the greater troch. • Imaging: -AP and cross-table lateral -Bone scan or MRI may be useful in nondisplaced or occult fractures

23. Classification of Intertrochanteric Hip Fractures • Kyle: -Type I: nondisplaced, stable -Type II: displaced into varus with a small lesser troch. fragment -Type III: displaced into varus, posteromedial comminution and greater troch. fracture -Type IV: Type III with subtrochanteric extension • Other classifications: Boyd and Griffin, Evans, and Zuckerman

24. Treatment of Intertrochanteric Hip Fractures • Nonoperative: only for patients who are an extreme risk for surgery • Sliding hip screw (130 degrees-150 degrees) -Screw placement should be within 1cm of subchondral bone -Screw should be located slightly posterioinferior or centrally in the femoral head

25. Treatment of Intertrochanteric Hip Fractures • Prosthetic replacement -For patients with failed ORIF -Calcar replacement hemiarthroplasty or bipolar endoprosthesis • Cephalomedullary nails for reverse obliquity fracture pattern • Greater troch. displacement should be fixed with tension banding • Large posteriomedial fragments should be fixed with a lag screw or cerclage wires

26. Complications of Intertrochanteric Hip Fractures • Fixation failure • Malunion • Nonunion • Infection • Acetabular penetration • Pressure sores

27. Subtrochanteric Hip Fractures • Fracture between the lesser troch. and a point 5 cm distal to the lesser troch. • Closed reduction difficult because straight femoral traction does not neutralize deforming muscle forces -Proximal Fragment: Abduction (gluteus), External Rotation (short rotators), Flexion (psoas) -Distal Fragment: Varus (adductors)

28. Subtrochanteric Hip Fractures • Frequent site for pathological fractures, 17-35% of all subtroch. fractures • Mechanism of injury: -High energy trauma in younger patients with normal bone -Minor fall in older patients with weakened bone

29. Seinsheimer Classification • Type I: nondisplaced fracture or any fracture with <2mm of displacement of the fracture fragments • Type II: -A: two-part transverse femoral fracture -B: two-part spiral fracture with the lesser troch. attached to the proximal fragment -C: two-part spiral fracture with the lesser troch. attached to the distal fragment

30. Seinsheimer Classification • Type III: -A: three part spiral fracture in which the lesser troch. is part of the 3rd fragment -B: three part spiral fracture of the proximal third of the femur, with the 3rd part a butterfly fragment

31. Seinsheimer Classification • Type IV: Comminuted fracture with four or more fragments • Type V: Subtroch-intertroch fracture, any subtroch. fracture with extension into the greater troch. • Other Classifications: -Fielding: based on location of primary fracture line in relation to lesser troch. -AO: based on comminution of fracture

32. Nonoperative Treatment of Subtrochanteric Hip Fractures • Reserved for poor operative candidates • Skeletal traction in the 90/90 position followed by spica casting or cast bracing • Associated with increased morbidity and mortality

33. Operative Treatment of Subtrochanteric Hip Fractures • Choice of fixation dependent on the involvement of the trochanters -Intact greater and lesser trochs.: conventional locked IM nail -Intact greater troch., fractured lesser troch.: recon nail (2nd gen. IM device) -Fractured greater and lesser trochs. 95 degree blade plate or dynamic compression screw

34. Complications of Subtrochanteric Hip Fractures • Malunion • Nonunion • Loss of fixation • Technical difficulty of fixation device

35. Ankle Fractures • The most common type of fracture treated by orthopedic surgeons • Only slight variation from normal is compatible with good joint function • Imaging: AP, lateral, and mortise views

36. Ankle Anatomy • Complex hinge joint with articulations with the fibula, tibia, and talus • Ligaments: -Deltoid ligament: superficial and deep -ATFL -PTFL -Calcaneofibular -Syndesmosis: anterior and posterior inferior tibiofibular ligaments, inferior transverse ligament, and interosseous ligament

37. Lauge-Hansen: Supination-Adduction • 10-20% of malleolar fractures • Stage I: transverse/avulsion fracture of the distal fibula or a rupture of the lateral collateral ligaments • Stage II: vertical fracture of the medial malleolus

38. Lauge-Hansen: Supination-External Rotation • Most common malleolar fracture • Stage I: disruption of the ATFL with or without an avulsion fracture at its attachment • Stage II: spiral fracture of the distal fibula • Stage III: disruption of the PTFL or a fracture of the posterior malleolus • Stage IV: transverse/avulsion fracture of the medial malleolus or a rupture of the deltoid ligament

39. Lauge-Hansen: Pronation-Abduction • Stage I: transverse fracture of the medial malleolus of rupture of the deltoid ligament • Stage II: rupture of the syndesmotic ligaments or an avulsion fracture at their insertions • Stage III: transverse or short oblique fracture of the distal fibula at or above the level of the syndesmosis

40. Lauge-Hansen: Pronation-External Rotation • Stage I: transverse fracture of the medial malleolus or rupture of the deltoid ligament • Stage II: disruption of the ATFL with or without avulsion fracture at its insertion sites • Stage III: spiral fracture of the distal fibula at or above the level of the syndesmosis • Stage IV: rupture of the PTFL or avulsion fracture of the posteriolateral tibia

41. Weber Classification • Based on the level of the fibular fracture • Type A: fracture below the level of the syndesmosis • Type B: oblique or spiral fracture at the level of the syndesmosis • Type C: fracture above the level of the syndesmosis

42. Fracture Variants • Maisonneuve fx: ankle injury with a fracture of the proximal third of the fibula, PER • Curbstone fx: avulsion fracture of the posterior tibia • LeForte-Wagstaffe fx: anterior fibular tubercle avulsion by ATFL, SER • Tillaux-Chaput fx: avulsion of anterior tibia by ATFL

43. Treatment of Ankle Fractures • Reduce dislocated ankles prior to x-rays • Cover open fractures with sterile, saline soap dressing, antibiotics, tetanus, etc. • Nonoperative(closed reduction): reserved for stable fracture patterns with an intact syndesmosis • Operative treatment required when closed reduction requires forced abnormal positioning of the foot, unstable fractures, open fractures, and widening of the mortise (1-2mm)

44. Operative Treatment of Ankle Fractures • Key to reduction is restoration of fibular length: lag screw and 1/3 tubular plate • Medial malleolus can be held with 2 cancellous screws perpendicular to the fracture line • Posterior malleolus should be fixed if there is >2mm of displacement or involvement of >25% of the articular surface • Syndesmotic screw for fibula fractures above the syndesmosis, placed 1.5-2cm above the joint line from the fibula to the tibia

45. Complications of Ankle Fractures • Nonunion • Malunion • Infection • Posttraumatic arthritis • Compartment Syndrome • Reflex sympathetic dystrophy • Tibiofibular synostosis

46. Pilon Fractures • Mechanism of injury: -Axial compression force through the talus -Shear: rotation combined with a varus or valgus stress • Etiology: mva, fall from height, direct crush injury, and sporting injuries (ski boot) • Imaging: AP, lateral, and oblique x-rays; CT scan for articular surface

47. Ruedi and Allgower Classification • Based on the severity of comminution and displacement of the articular surface • Type I: nondisplaced with splitting fracture lines • Type II: articular surface displaced; split fracture types • Type III: significant comminution and displacement of articular surface • Other classifications: AO, Mast, and Ovadia and Beale

48. Treatment of Pilon Fractures • ORIF of the fibula with 1/3 tubular plate • Reconstruction of tibial joint surface with K-wires • Bone graft metaphyseal deficits • Plate tibia (medial malleolus), cloverleaf plate • Fractures with metaphyseal comminution and severe soft-tissue injury consider external fixation

49. Complications of Pilon Fractures • Skin slough • Infection • Nonunion • Malunion • Posttraumatic arthritis • Joint stiffness