Transcript Lower limb fractures and dislocation

Lower limb fractures
and dislocation
DR. MOHAMAD KHAIRUDDIN BIN ABDUL WAHAB
M.B.B.S (Univ. Malaya), MS Ortho (UKM)
ORTHOPAEDIC SURGEON
FACULTY OF MEDICINE
CUCMS
Learning outcome:
The student should be able to:
 Discuss on the mechanism, clinical
presentation, classification, radiological
findings, and its complications of fractures
and joint dislocation
 Derive treatment option of the common
lower limb fractures and joint dislocation
Contents:
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FRACTURE NECK OF FEMUR
INTERTROCHANTERIC FRACTURE
HIP JOINT DISLOCATION
FEMUR SHAFT FRACTURE
DISTAL FEMUR FRACTURE
KNEE JOINT DISLOCATION
PATELLA FRACTURE
TIBIAL PLATEAU FRACTURE
CONT’:
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TIBIA SHAFT FRACTURE
MALLEOLI FRACTURE
TALUS FRACTURE
CALCANEUM FRACTURE
Fracture neck of femur
 Common in elderly following fall (osteoporosis)
 Young adult is due to high energy impact such as
road traffic accident
 May accompanied hip joint dislocation (high
impact injury)
Demonstrated radiological (AP view of hip joint) as:
 Loss of Shenton’s line
 Disruption of proximal femur trabecula
Classification:
 Garden’s classification (4 stages) for
femur neck fracture
 Help to determine the management and
predict the prognosis on complication
(avascular necrosis of the femoral head)
Garden’s classification
Stage I
Incomplete # (impacted)
Stage II
Complete and undisplaced
Stage III
Complete and moderately
displaced
Severely displaced
Stage IV
Anatomical classification:
 Also can describe the pattern of neck
fracture
 Subcapital region
 Transcervical region
 Basal region
 Prognosis for AVN worsen in subcapital
and transverse fracture
Radiological features of neck of femur fracture
Shenton’s line
Complication:
 Avascular necrosis of the femur head
 Non-union of the fracture
 General complications following prolong
bedridden for conservative treatment
(bedsore, DVT, pneumonia, stiffness)
Treatment:
 Depend on the age of the patient,
patient’s health and fracture stages &
duration
Non-operative reserve for:
 Poor health (unfit for surgery) patient
 Require on Traction for 3 – 6 weeks then
start ambulate
Cont’:
Operative treatment is the main goal:
 Younger age group with acute # and elderly
with impacted # (preserved the head) usage of
fracture fixation devices eg. Screw fixation,
Dynamic Hip Screw
 Elderly patient with displaced # or chronic #
subjected to hip replacement (hemiarthroplasty
or total arthroplasty of the hip joint)
Intertrochanteric fracture
 Commonly occur in elderly patient
(osteoporosis) following trivial fall
 Extension to subtrochanteric region
 May presented as comminuted fracture
pattern
Radiograph shows intertrochanteric
fracture of the femur
Complications:
 Mal-union of the fracture
 Failure in fixation for the fracture due to
osteoporotic bone
 General complications following prolong
bedridden
Treatment
 Operative is the main goal except unfit
patient for anaesthesia or extreme
osteoporotic bone
Choices of implant for fracture fixation:
 Dynamic Hip Screw
 Proximal femoral nail (PFN)
Fixation of fracture intertrochanteric fracture
Hip joint dislocation
 Direction: posterior is more common than
anterior
 Mechanism: ‘dash-board’ injury
 Limb attitude:
 Posterior dislocation (flexed, adducted,
internally rotated, short limb)
 Anterior dislocation (flexed, externally
rotated, abducted)
 Association with acetebular fractures of
femoral head fractures
Left side
Radiograph shows left hip dislocation
Complications:
 Sciatic nerve injury leading muscle
paralysis and loss of sensory below the
knee
 Prolong dislocation can also result in
avascular necrosis of the femoral head
Treatment
 Emergency CMR under sedation
 Failure in CMR  open reduction
 Failure in CMR to obtain acceptable
reduction is due to:
 Inverted limbus of the acetebular rim
 Intra-articular fracture fragment
Femoral shaft fractures
 Area that is well padded with muscles
leading to fracture displacement and
difficulty in CMR and maintain the reduction
 Associated with soft tissue injury due to
high-energy injury risk of getting
compartment syndrome
 Long bones – segmental #
 Occasionally associated with # neck of
femur
Radiographs show femur shaft fractures
Distal 1/3
supracondyalar
Proximal 1/3
Complication
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Vascular injury (femoral artery)
Fat embolism
Delayed and non-union of the fracture
Mal-union of the fracture
Joint stiffness (knee)
Treatment
 Less preference for non-operative
treatment (as the bone is weight bearing
region) in adult
Operative fracture fixation used :
 Intramedullary-Locking-Nail
 Plating (DCP)
Intramedullary locking
nail
Distal femur #: Supracondylar
& intercondylar
 Supracondylar # can be isolated or
combination with intercondylar #
 Result from high energy force
 Risk of vascular injury (femoral artery)
 Intercondylar extension may involved
articular region of the knee
Complications
 Joint stiffness and arthrosis if involve the
articular region
 Risk of femoral artery injury
Treatment
 Open Reduction Internal Fixation is a goal
standard treatment
Fixation devices:
 Angled blade plate
 CDS (condylar dynamic screw)
 Supracondylar inter-locking nail
 Buttress plating (locking plate)
Angled blade plate for fixation
of supracondylar fracture
of the femur
Knee joint dislocation
 Result from violence injury force
 Involve more than two of knee ligaments
injury
 Can presented as ‘self-reduction’ joint
dislocation
 Associated with popliteal vessel injury
and common peroneal nerve injury
 Urgent attention for vascular assessment
Radiographs show anterior
dislocation of the knee
Risk of vascular injury
 Transected or thrombosis (following
intimal injury)
 Vascular assessment or surveillance
 Angiogram as indicated
Directions of dislocation
 Reference to the position of tibia
 Anteromedial dislocation (risk of
associated intimal injury of popliteal
artery)
 Posterolateral dislocation (highly
associated with transected popliteal
artery)
artery
Complications
 Neurovascular injury
 Knee ligaments injury (result in joint
instability)
 Stiffness of the joint
 Arthrosis formation following cartilage
damage
Treatment
 Immediate reduction and immobilization
 Artery exploration and repair in the
evidence of arterial injury
 Immobilization in cast (FLPOP) or
external fixation
 Ligaments repair or reconstruction for
multiple ligaments injury resulting in
instability
Tibial plateau fractures
 Mechanism: varus or valgus force
combined with axial loading
 Also known as ‘bumper fracture’
 Tibial condyle can be crushed or split
 Presentation: haemathrosis, instability,
associated neurovascular injury
Types of TP #
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Simple split lateral condyle
Depressed, comminuted lateral condyle
Crushed comminuted lateral condyle
Split medial condyle
Bicondylar fractures
Bicondylar and subcondylar
Complications
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Compartment syndrome
Joint stiffness
Deformity
arthrosis
Treatment
Undisplaced or minimally displaced
 Traction until swelling subsided, apply cast
immobilization
Displaced and depressed
 Open reduction and internal fixation (buttress
plate, inter-fragmentary screw)
 May need bone grafting in depressed fractures
Patella fractures
 Direct injury (dash board, direct fall onto
the knee) produced ‘stellate’ fracture
 Indirect injury (forced flexion knee)
produce avulsion type or simple
transverse pattern
 Loss of extensor mechanism
 Haemathrosis
Complications
 Joint stiffness
 Patellofemoral arthrosis
 reduced knee extensor mechanism
Treatment
Undisplaced fracture
 Cylinder cast immobilization for 6 weeks
Displaced fracture
 ORIF (tension band wiring)
Severely comminuted
 Cerclage wiring or patellectomy
Tibial shaft fractures
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Proximal, middle, distal region
Compartment syndrome (proximal 1/3)
Affecting union (distal 1/3)
Spiral, oblique (indirect force)
Transverse, comminuted (direct force)
With or without fibular shaft #
Radiographs show tibial shaft fracture
Complications
 Compartment syndrome
 Malunion (leading to shortening and
arthrosis)
 Nonunion
Treatment
Acceptable displacement with less
comminuted (stable)
 Apply Full Length POP immobilization for
6 weeks
Comminuted, segmental (unstable
reduction alignment)
 Internal fixation (ILN, Plating)
Intramedullary
Locking nail for
Tibia shaft fracture
Malleoli fractures
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Forces to the ankle region
External rotation, abduction, adduction,
Ankle joint dislocation or subluxation
Ankle ligaments injury including
syndesmosis
Classification
 Danis & Weber (Muller et al 1991):
Type A: # below the tibiofibular
syndesmosis
 abduction or adduction force
 Medial malleolus may #ed or rupture of
deltoid ligament
Cont’:
Type B: # level with syndesmosis
 Oblique fibular #
 External rotation force
 Disrupted medial structures
 Syndesmosis intact
Cont’:
Type C: # above the syndesmosis
 Abduction alone or combination of
abduction and external rotation force
 Disruption of syndesmosis and
interosseous membrane (widened
mortise)
 Unstable tibiofibular region
Fracture of lateral
malleolus
Complications
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Dislocated or subluxated ankle joint
Stiffness
Arthrosis of ankle joint
Ankle instability
Nonunion fracture (displaced medial
malleolus)
 Malunion of the fracture
Treatment
Undisplaced #
 Cast immobization (boot POP)
Displaced # with or without subluxation
joint or loss of normal ankle mortise
 ORIF (fibular plating, screw fixation of
medial malleoli, syndesmotic screw)
Plating of the lateral malleolus fracture
with 1/3 tubular plate
Talus fractures
 Rare injury
 Violence injury (following inversion force or
axial loading)
 +/- dislocation of the ankle joint or subtalar joint
 Regions affected: head, neck, body, and lateral
process
 Risk of developing avascular necrosis of talus
dome
Talus fractures
Neck of talus fracture
Dome of talus fracture showed
Through CT-scan
Complications
 Skin damage or necrosis due to pressure
from the underling bone
 Nonunion of the fracture
 AVN following fracture at the neck region
 Arthrosis (ankle and subtalar)
Treatment
 Undisplaced #: cast immobilization (boot
POP)
 Displaced # +/- dislocation: ORIF screw
fixation
 If AVN developed later may consider
arthrodesis of the ankle joint
Screw fixation of the talus fracture at the neck region
Calcaneum fractures
 Result from axial loading
 Traction through Achilles tendon lead to
avulsion fracture
 Can be extra-articular or intra-articular
fracture (referring to subtalar joint)
 Result in loss of foot arch (Bohler’s
angle: 25 –40 degrees) lead to flat foot
Extra-articular fracture of calcaneum
Complications
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Skin necrosis (intense swelling)
Malunion of the fracture
Peroneal tendon impingement
Flat and broad foot (shoe fitting)
Subtalar arthrosis
Treatment
 Extra-articular fractures or undisplaced
intra-articular fractures may require
Robert-Jones bandaging for 1 week then
followed by boot POP cast for 5 weeks
 No weight bearing is allowed
 Displaced intra-articular # or avulsion of
Achilles insertion: ORIF screw or recon
plate
Exercise for student:
After reviewing the lecture notes, you are
require to do some exercises.
The answers to the exercise need to be
submitted via e-mail (address:
[email protected])
Questions:
 Briefly discuss on the classification used
to describe neck of femur fracture.
 With regards to dislocated knee,
describe the direction of dislocation in
relation to vascular injury pattern.
 Briefly discuss on the complications
following calcaneum fracture.
Reference for further
reading:
 Orthopaedic Surgery Essential: Trauma;
Charles Court-Brown, Lippincott Williams &
Wilkins; 2005
 Turek’s Orthopaedics: Principles & their
application; Stuart L. Wienstein, Joseph A.
Backwalter: 5th Edition Lippincott Williams &
Wilkins 2005
 Practical Fracture Treatment; Ronald McRae, Max
Esser; 4th Edition, Churchill Livingstone 2002
Enjoy reading…..
For further questions or enquiry , please contact through:
Handphone: 012-8976094
Email
: [email protected]