Common lower limb fracture Dr TarifAlakhras Orthopedic 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 LigamentumTeres • 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 • Intertrochantericand subtrochanteric fractures do not involve the neck of femur
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 ligamentousstability (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 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 area from 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 fractures Coexisting 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 fractures nonsurgical 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 treatment Plate 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 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 Bimalleolarfeactur
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