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Femur and Tibia Fractures

Femur and Tibia Fractures

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Femur and Tibia Fractures

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  1. Femur and Tibia Fractures Kevin E. Coates, M.D., M.P.T.

  2. Worker’s Compensation?

  3. Femoral Neck Fractures • Epidemiology • 250,000 Hip fractures annually • Expected to double by 2050 • At risk populations • Elderly: poor balance&vision, osteoporosis, inactivity, medications, malnutrition • incidence doubles with each decade beyond age 50 • higher in white population • Other factors: smokers, small body size, excessive caffeine & ETOH • Young: high energy trauma

  4. Classification • Garden • I Valgus impacted or • incomplete • II Complete • Non-displaced • III Complete • Partial displacement • IV Complete • Full displacement • ** Portends risk of AVN and Nonunion I II III IV

  5. Treatment • Goals • Improve outcome over natural history • Minimize risks and avoid complications • Return to pre-injury level of function • Provide cost-effective treatment

  6. TreatmentDecision Making Variables • Patient Characteristics • Young (arbitrary physiologic age < 65) • High energy injuries • Often multi-trauma • Elderly • Lower energy injury • Comorbidities • Pre-existing hip disease

  7. TreatmentYoung Patients(Arbitrary physiologic age < 65) • Non-displaced fractures • At risk for secondary displacement • Urgent ORIF recommended • Displaced fractures • Patients native femoral head best • AVN related to duration and degree of displacement • Irreversible cell death after 6-12 hours • Emergent ORIF recommended

  8. Hemi ORIF THR

  9. Non-displaced Fractures • ORIF standard of care • Predictable healing • Nonunion < 5% • Minimal complications • AVN < 8% • Infection < 5% • Relatively quick procedure • Minimal blood loss

  10. Displaced FracturesHemiarthroplasty vs. ORIF • ORIF is an option in elderly Surgical emergency in young patients • Complications • Nonunion 10 -33% • AVN 15 – 33% • AVN related to displacement • Early ORIF no benefit • Loss of reduction / fixation failure 16%

  11. Displaced FracturesHemiarthroplasty vs. ORIF • Hemi associated with • Lower reoperation rate (6-18% vs. 20-36%) • Improved functional scores • Less pain • More cost-effective • Slightly increased short term mortality

  12. Femoral Neck Nonunion • Definition: not healed by one year • 0-5% in Non-displaced fractures • 9-35% in Displaced fractures • Increased incidence with • Posterior comminution • Initial displacement • Inadequate reduction • Non-compressive fixation

  13. Femoral Neck FracturesComplications • Failure of Fixation • Inadequate / unstable reduction • Poor bone quality • Poor choice of implant • Treatment • Elderly: Arthroplasty • Young: Repeat ORIF Valgus-producing osteotmy Arthroplasty

  14. Femoral Neck FracturesComplications • Post-traumatic arthrosis • Joint penetration with hardware • AVN related • Blood Transfusions • THR > Hemi > ORIF • Increased rate of post-op infection • DVT / PE • Multiple prophylactic regimens exist • One-year mortality 14-50%

  15. Intertrochanteric Femur Fractures • Intertrochanteric Femur • Extra-capsular femoral neck • To inferior border of the lesser trochanter

  16. Etiology • Osteoperosis • Low energy fall • Common • High Energy • Rare

  17. Radiographs • Plain Films • AP Pelvis • Cross Table Lateral

  18. Goals of Treatment • Obtain a Stable Reduction • Internal Fixation • Good Position • Mechanically Adequate • Permit Immediate Transfers & Early Ambulation

  19. Rehabilitation • Mobilize • Weight Bearing As Tolerated • Cognitive Intact Patients Auto Protect • Unstable Fractures = Less WB • Stable Fractures = More WB • No Difference @ 6 weeks Post op

  20. Femoral Shaft Fractures • Common injury due to major violent trauma • 1 femur fracture/ 10,000 people • More common in people < 25 yo or >65 yo • Femur fracture leads to reduced activity for 107 days • Motor vehicle, motorcycle, auto-pedestrian, aircraft, and gunshot wound accidents are most frequent causes

  21. Femur FractureManagement • Initial traction with portable traction splint or transosseous pin and balanced suspension • Evaluation of knee to determine pin placement • Timing of surgery is dependent on: • Resuscitation of patient • Other injuries - abdomen, chest, brain • Isolated femur fracture

  22. Femur FractureManagement • Antegrade nailing is still the gold standard • Antegrade nailing problems: • Varus alignment of proximal fractures • Trendelenburg gait • Can be difficult with obese or multiply injured patients

  23. Femur FractureManagement • Retrograde nailing has advantages • Easier in large patients to find starting point • Better for combined fracture patterns (ipsilateral femoral neck, tibia,acetabulum) • Retrograde nailing has its problems: • Intra-articular starting point

  24. Femur FractureComplications • Hardware failure • Nonunion - less than 1-2% • Malunion - shortening, malrotation, angulation • Infection • Neurologic, vascular injury • Heterotopic ossification

  25. Ipsilateral Femoral Neck & Shaft Fractures • Optimum fixation of the femoral neck should be the goal • Varus malunion of the femoral neck is not uncommon, osteotomies can lead to poor results • Vertical femoral neck fracture seen in 26-59% of cases • Rate of avascular necrosis is low, 3%, even when missed

  26. Tibial Plateau Fractures • Mechanism of Injury • Mean age in most series of tibial plateau fractures is about 55 years • Large percentage over age 60 • Elderly population is increasing in numbers

  27. Mechanism of Injury • Mechanism of injury is fall from standing height in most patients • MVA is increasing as % of fractures • Most common fracture pattern is split-depressed fracture of lateral tibial plateau (80% of fractures)

  28. Physical Exam • Neurologic exam • peroneal nerve! • Vascular exam • popliteal artery and medial plateau injuries • beware the of the knee dislocation posing as a fracture • beware of posteriorly displaced fracture fragments • ABI <0.9 urgent arterial study

  29. Physical Exam • Compartment syndrome • KNEE STABILITY • varus/valgus in full extension • may require premedication • aspiration of knee effusion/hematoma • replace with lidocaine+marcaine

  30. Evaluation of Soft Tissues • Proximal and distal tibia subcutaneous • Soft tissue remains compromised for at least 7 days • Early ORIF risks wound sloughexposed hardware

  31. AP and Lateral Radiographs

  32. Pre-traction

  33. Post-traction

  34. Computed Tomography • Indications • Fracture in an active patient for which you are considering nonsurgical care • Complex fracture • To aid surgical planning of approach, technique, screw position, etc.

  35. Computed Tomography

  36. Computed Tomography

  37. Classification:Schatzker I III II

  38. Classification:Schatzker IV VI V

  39. Surgical Indicatons • Open Fracture – I&D, spanning ex-fix • Extensive soft tissue contusion – spanning ex-fix • Closed fracture • Varus/valgus instability of the knee • Varus or valgus tilt of the proximal tibia • Meniscal injury/previous mensicectomy • Articular displacement or gapping???

  40. Angular Malalignment of the Proximal Tibia • Incidence of arthrosis: • Valgus < 10o 14% • Valgus > 10o 79% • Any amount of varus angulation was bad • Independent of articular congruity

  41. Meniscectomy • Higher rate of arthrosis in patients who had undergone meniscectomy at surgery • 70% arthrosis in patients who had undergone meniscectomy • results independent of the amount of articular incongruity

  42. Postoperative Management • Immediate PROM/AROM of knee • Routine Pin site care (if ex-fix) • TDWB for 8-12 weeks

  43. Outcomes • Outcome depends on: • Varus valgus stability of the knee • Varus/valgus alignment of the proximal tibia • Presence of an intact meniscus • Articular congruity (to a lesser extent)

  44. Treatment Goals • Focus on restoring stability and proximal tibial alignment to the knee, rather than restoring anatomic alignment of the articular surface at all costs • Use minimally invasive techniques, when possible • Other techniques are preferable to hybrid ex-fix • MOVE THE KNEE EARLY IN ALL PATIENTS!

  45. Tibial Shaft Fractures Mechanism of Injury • Can occur in lower energy, torsional type injury (eg, skiing) • More common with higher energy direct force (eg car bumper)

  46. Physical Exam • Soft tissue injury with high-energy crush mechanism may take several days to fully declare itself • Repeated exam often necessary to follow compartment swelling

  47. Associated Injuries • Up to 30% of patients with tibial fractures have multiple injuries* • Fracture of the ipsilateral fibula common • Ligamentous injury of knee common in high energy tibia fractures

  48. Associated Injuries • Ipsilateral femur fx, so called “floating knee”, seen in high energy injuries • Neuro/vascular injury less common than in proximal tibia fx or knee dislocation • Foot and ankle injury should be assessed on physical exam and x-ray if needed

  49. Compartment Syndrome • 5-15% • History of high energy or crush injury

  50. Nerve is the Tissue most Sensitive to Ischemia • PAIN first Symptom • PAIN with Passive Stretch first Sign