lower limb fractures part 1 (for ugs)
TRANSCRIPT
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Lower Extremities Fractures (Part I)
Dr. Apoorv JainD’Ortho, DNB Ortho
[email protected]+91-9845669975
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• Pelvic Fractures• Fracture Neck Of
Femur• Intertrochanteric
Fracture Femur• Fracture Shaft Of
Femur
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Pelvic Fractures
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Pelvic FracturesRelevant Anatomy:• The pelvic ring is composed of the sacrum and
two innominate bones joined anteriorly at the symphysis and posteriorly at the paired sacroiliac joints.
• The innominate bone is formed at maturity by the fusion of three ossification centers: – the ilium– the ischium, and – the pubis
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The pelvic brim is formed by the arcuate lines that join the sacral promontory posteriorly and
the superior pubis anteriorly.
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Mechanism Of Injury• Low-energy injuries:
– As in sudden muscular contractions in young athletes that cause an avulsion injury, a low-energy fall, or a straddle-type injury
• High-energy injuries:– Motor vehicle accidents, fall from heights, or crush
mechanism– Impact injuries result when a moving victim strikes
a stationary object or vice versa– Crush injuries occur when a victim is trapped
between the injurious force
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Avulsion Fractures:• Common in Athletes• Pull Of Sartorius will cause?
– Anterior Superior Iliac Spine avulsion• Pull Of Rectus femoris will cause?
– Anterior Inferior Iliac Spine avulsion• Pull of Hamstrings?
– Ischial Tuberosity avulsion• Pull Of Adductor Longus?
– Pubic avulsion fracture
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Clinical evaluation
• Perform patient primary assessment (ABCDE):– Airway Maintenance with C-spine protection – Breathing and Ventilation – Circulation with hemorrhage control – Disability: Neurologic status – Exposure/Environment Control
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• Initiate resuscitation: Address life-threatening injuries
• Evaluate injuries to head, chest, abdomen, and spine.
• Identify all injuries to extremities and pelvis, with careful assessment of distal neurovascular status
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• Pelvic Compression Test: – The Antero-Posterior and Lateral Compression
test for pelvic instability should be performed once only and involves rotating the pelvis internally and externally.
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Remember: “The first clot is the best clot” Once disrupted, subsequent thrombus formation of a retroperitoneal hemorrhage is difficult because of hemodilution by administered intravenous fluid and exhaustion of the body’s coagulation
factors by the original thrombus
To be done once only
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• Massive flank or buttock contusions are indicative of significant bleeding
• The perineum must be carefully inspected for the presence of a lesion representing an open fracture
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Hemodynamic status• Retroperitoneal hemorrhage/ a large-vessel injury,
such as external or internal iliac disruption• Causes rapid, massive hemorrhage and marked
hemodynamic instability• Pelvic Binder, Rapid Fluid Resuscitation, Monitoring
(Pulse, BP, Urinary Output) are crucial• Often, immediate surgical exploration to control
bleeding is required
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Associated Injuries• Neurologic injury:
– Lumbosacral plexus and nerve root injuries
• Genitourinary and gastrointestinal injury– Bladder injury: 20% incidence – Urethral injury: 10% incidence
• Look for blood at the urethral meatus or on catheterization
– Perforations in the rectum or anus, entrapment of bowel with GI obstruction may occur
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Radiographic evaluation• Standard trauma radiographs include:
– AP view of the chest– Lateral view of the cervical spine– AP view of the pelvis
• In an AP view of the pelvis look for:– Anterior lesions: pubic rami fractures and symphysis
displacement– Sacroiliac joint and sacral fractures– Iliac fractures– L5 transverse process fractures
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• Special views of the pelvis include:– Obturator and iliac oblique views (Judet Views): For
suspected acetabular fractures– Inlet and Outlet views
• Computed tomography• Magnetic resonance imaging
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Classifications
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Young-Burgess classification
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AP Compression Type
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Treatment
• Nonoperative (Conservative) for– Undisplaced/ Minimally displaced, Stable fractures– Gaping of pubic symphysis <2.5 cm– Isolated pubic rami fractures
• Includes Bed Rest, Traction, in bed mobilisation followed by Gradual assisted weight bearing
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• Operative Techniques–External fixation –Internal fixation
• Open reduction and stable internal fixation are performed using lag screws and neutralization plates.
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Complications• Infection• Thromboembolism:
– Disruption of the pelvic venous vasculature and immobilization constitute major risk factors for the development of deep venous thromboses.
• Malunion• Nonunion
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Fractures Around Hip
• Includes:–Acetabular Fractures–Fracture Head Of Femur–Fracture Neck Of Femur–Intertrochanteric Fracture Femur
Frequently Associated With Hip Dislocation
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Fracture Neck Of Femur
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Fracture Neck Of Femur• Occurs usually in elderly population• The average age of occurrence is 77 years
for women and 72 years for men• 80% occur in women• The incidence in younger patients is very
low and is associated mainly with high-energy trauma
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• Risk factors include:–female sex–white race– increasing age–poor health–tobacco and alcohol use–previous fracture/ fall history, and– low estrogen level (Post Menopausal)
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Mechanism of injury• Low-energy trauma: Most common in older patients:
– Direct: A fall onto the greater trochanter (valgus impaction) or forced external rotation of the lower extremity
– Indirect: Muscle forces overwhelm the strength of the femoral neck.
• High-energy trauma: Such as motor-vehicle accident or fall from a significant height
• Cyclical loading (Stress fractures): Seen in athletes, military recruits, ballet dancers; patients with osteoporosis and osteopenia are at particular risk.
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Clinical evaluationTypically are nonambulatory on presentation
(Patients with impacted or undisplaced fractures may however demonstrate subtle findings and may
be able to bear weight)External rotation of the lower extremityShorteningPainful range of movementsPain on axial compressionTenderness in the groin
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Radiographic Evaluation• An AP view of the pelvis• an AP and a Cross-table Lateral view of the
affected hip• A 15° Internal rotation view (True AP) of the
injured hip may be helpful to further clarify the fracture pattern.
A True AP view is taken with limbs in
15° Internal Rotation
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A Cross-table Lateral view of the affected hip is obtained by
flexing the uninjured hip and knee 90
degrees and aiming the beam into the
groin, parallel to the floor and
perpendicular to the femoral neck
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Technetium Bone Scan or preferably Magnetic resonance imaging may be used to identify undisplaced or occult fractures that are not apparent on plain radiographs
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Classification• Anatomic Location
– Subcapital– Transcervical– Basicervical (Treated as ExtraCapsular)
Treated as IntraCapsular
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Pauwel’s Classification:• Based on the angle of fracture from the horizontal:
– Type I: <30 degrees – Type II: 30-70 degrees – Type III: >70 degrees
More the angle, more unstable the fracure
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Garden Classification:• Based on the degree of valgus displacement
Type I: Incomplete/valgus impacted Type II: Complete and undisplacedType III: Complete with partial displacement; trabecular pattern of the femoral head does not line up with that of the acetabulum Type IV: Completely displaced; trabecular pattern of the head assumes a parallel orientation with that of the acetabulum
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Treatment Algorithm(for fracture neck of Femur)
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Undisplaced
Displaced
Hemiarthroplasty/Total Hip Arthroplasty
OldYoung
Percutaneous Screw or Arthroplasty
PercutaneousCancellous Screw
Open Reduction &Internal Fixation
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Internal Fixation For Fracture Neck Of Femur (For Younger Patients)
Percutaneous Cancellous Screw Fixation
Fixation With a DHS and Derotation Screw
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Elderly Patients(Physiological age>60 years)
Hemireplacement Arthroplasty
Total Hip Replacement
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Complications
• Non Union• Osteonecrosis Of Femoral head:
– Seen in upto 10% of nondisplaced fractures and upto 27% of displaced fractures
• Fixation failure• Prominent Hardware/ Screw backout• Infection
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Non Union Fracture Neck Of Femur:• As per FDA, a fracture neck femur is said to be
non united if does’nt heal in 3 months• Causes include:
– Intra-articular location(Synovial fluid causes the lyses of the blood clot)
– Absence of Cambium layer(Hence there is lack of callus and healing is only endosteal)
– Vascular Anatomy– Inadequate reduction– Loss of fixation
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• Clinically,–Shortening/ contractures–Externally rotated limb–Telescopy+
• Radiologically,–Absorption of neck–Roundening of fracture margins–Evidence of hip arthritis may be present
in long standing cases
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• Treatment options for Fracture Non-Union Neck Of Femur:– Elderly patient (Physiological age>60):
• Hemiarthroplasty (AMP/Bipolar)• Total Hip Replacement (if Osteoarthritis+)
– Younger Patients:• Open Reduction and Internal Fixation with
Cancellous Bone graft• Muscle pedicle graft/ Vascularised grafts• Osteotomy• Purchase time for Total Hip Replacement if
evidence of Osteoarthritis+
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Intertrochanteric Fracture Femur
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Intertrochanteric Fracture Femur
• Account for nearly 50% of all fractures of the proximal femur
• Average patient age of incidence is 66 to 76 years
• Risk factors include– Female sex (2-8 times commoner in females)– Advancing age– History of fragility fractures and– Osteoporosis
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Relevant Anatomy• These are extracapsular fractures• Occur in cancellous bone with an abundant blood
supply. As a result, nonunion and osteonecrosis are not major problems, as in femoral neck fractures.
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• Deforming muscle forces will usually produce– Shortening– Abduction of proximal femur– Medial displacement, Adduction and proximal
migration of distal femur
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Mechanism of injury
• 90% of intertochanteric fractures in the elderly result from a simple fall
• Most fractures result from a direct impact to the greater trochanter
• In younger individuals they usually occur as a result of high-velocity injuries such as a motor vehicle accident or a fall from height
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Clinical Evaluation• Patients are usually nonambulatory with
– Lower extremity shortening– Externally rotated (>Fracture Neck Of Femur)– Tenderness over Greater Trochanter
– Range of hip motion is typically painful(Patients with undisplaced fractures may be ambulatory and
experience minimal pain)
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• Commonly associated injuries include,– Fractures of the Distal Radius– Proximal Humerus and– Spine (compression fractures)
• Must also evaluate for,– Potential Dehydration – Nutritional status– Pressure ulceration– Hemodynamic instability
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Radiographic Evaluation(similar to fracture neck of Femur)
• An AP view of the Pelvis• An AP and a Cross-table Lateral View of the
involved Hip• A 15° Internal Rotation View• Technetium Bone Scan or preferably MRI may
be useful in identifying undisplaced or occult fractures that are not apparent on plain radiographs.
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Fracture stability depends on the integrity of the Posteromedial bony cortex
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Evans Classification
Based On the Fracture Stability (Pre/Post reduction)
• Stable:– Intact or minimally comminuted Posteromedial Cortex
• Unstable: – Greater comminution of Posteromedial cortex– Reverse Oblique Fractures– Subtrochanteric Extension
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Stable Fracture Pattern with Intact/ Minimally comminuted Posteromedial
Cortex
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Unstable Fracture Pattern with,Greater comminution of Posteromedial
cortexReverse Oblique FracturesSubtrochanteric Extension
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Treatment Options1) Open Reduction/ Closed Reduction and Internal Fixation with,
– Dynamic Hip Screw (For Stable Fractures)– Intramedullary Nail– Fixed Angle Blade Plate
2) External Fixation (For Open/ Infected Fractures)3) Arthroplasty (For Associated Hip Osteoarthritis/ Fracture Neck Of Femur)
For Unstable Fractures
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Dynamic Hip Screw (Sliding hip screw)
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Intramedullary Fixation
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Complications
• Loss Of Fixation• Malunion (Usually malrotation, varus/valgus)• Non Union (Very rare, <2%)• Infection• Osteonecrosis Of femoral head (Rare)
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Remember,• For a displaced fracture neck of Femur or an
Intertrochanteric fracture Femur,Surgery is the treatment of choice
• Non-operative treatment is associated with a higher mortality rate than operative treatment
• Non-operative treatment indicated only for patients who are at extreme medical risk for surgery or for demented/nonambulatory patients with minimal hip pain
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Fracture Shaft Of Femur
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Fracture Shaft Of Femur• A femoral shaft
fracture is a fracture of the femoral diaphysis occurring between 5 cm distal to the lesser trochanter and 5 cm proximal to the adductor tubercle
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Age and Sex (Bimodal Distribution)
In Younger patients, More common in Men A High-velocity trauma
In Elderly patients, More common in Women A Low-energy fall
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Mechanism Of Injury• In Young Adults, almost always the result of
high-energy trauma,– Motor vehicle accident– Gunshot injury, or– Fall from a height
• Pathologic fractures, especially in the elderly, commonly occur following a trivial fall
• Stress fractures occur mainly in military recruits or runners
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Clinical Evaluation• A full trauma survey is indicated (ABCDE)• The patient is
– Nonambulatory with pain– Variable gross deformity– Swelling, and – Shortening of the affected extremity.
• A careful neurovascular examination is essential
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• A careful assessment of hemodynamic stability is essential,Average expected Blood loss of 750-1500ml
• Thorough examination of the ipsilateral hip and knee should be performed
• Knee ligament injuries are common, however, and need to be assessed after fracture fixation
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Thomas Splint Immobilisation before shifting the patient
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Associated Injuries• Present in up to 5% to 15% of cases,
– Multisystem trauma,– Spine,– Pelvis, and– Ipsilateral lower extremity injuries
• Ligamentous and meniscal injuries of the ipsilateral knee are present in 50% of patients with closed femoral shaft fractures
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Radiographic Evaluation• AP and Lateral views of the femur,
hip, and knee• AP view of the pelvis should be
obtained• Look for evidence of an associated
femoral neck or intertrochanteric fracture
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Classification• Descriptive Classification
– Open versus closed injury– Location: Proximal, Middle, or Distal one-third– Pattern: Spiral, Oblique, or Transverse– Comminution: Segmental, or Butterfly fragment– Displacement: Shortening or Translation,
Angulation or Rotational deformity
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Winquist and Hansen Classification• Based on fracture comminution,
– Type I: Minimal or No comminution – Type II: Cortices of both fragments are 50% intact – Type III: 50% to 100% cortical comminution – Type VI: Circumferential comminution with no
cortical contact
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Treatment• Operative stabilization is the standard
of care for most femoral shaft fractures• Surgical stabilization should occur
within 24 hours, if possible• Early stabilization of long bone injuries
appears to be particularly important in the multiply injured patient
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For patients in whom surgery needs to be delayed, temporary stabilisation with
Skeletal traction is required
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Fixation Options
• Intramedullary Fixation• Open Reduction and Plate Fixation• External Fixation
(For Open/ Infected Fractures)
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Intramedullary Fixation
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Plate Fixation
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External Fixation
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Treatment Of Fracture Shaft Of Femur In Children
As per AAOS guidelines,• Age <6months:
– Pavlik Harness/ Early Spica Cast• Age 6mts- 5 years:
– Early spica casting – Traction with delayed spica casting – ORIF with submuscular bridge plating– Flexible nails (Ender’s / TENS)– External fixator
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Pavlik Harness for Age<6months
Hip Spica Castfor Age upto 5 years
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Gallows Traction
PaediatricThomas Splint
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Flexible Intramedullary Nail Fixation
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• Age 6-11 years,– ORIF with submuscular bridge plating– Flexible nails (Ender’s / TENS)– External fixator
• Age>11 years,– Antegrade Intramedullary Interlocking nail– ORIF with submuscular bridge plating– Flexible nails (Ender’s / TENS)– External fixator
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Complications• Neurovascular injury• Complartment Syndrome• Infection• Fixation Failure• Non-Union/ Delayed Union• Malunion• Heterotopic Ossification
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Thank You