LOWER LIMB FRACTURES
DR. CODRIN HUSZAR University Hospital Bucharest
DISTAL FEMORAL FRACTURES
Ethiology
High energy trauma young / active patients (dashboard impact) Low energy trauma elderly (falls from the same level)
CLASSSIFICATION (A.O. / O.T.A.)
A SUPRACONDYLAR (EXTRAARTICULAR) B UNICONDYLAR (PARTIAL ARTICULAR) C SUPRA- AND INTERCONDYLAR
DISPLACEMENT
CLINICAL PRESENTATION
Swelling and regional deformity Patellar shock present
COMPLICATIONS
IMMEDIATE
Open Fx. Neuro-vasc injuries Soft tissue entrap.
EARLY
DVT Infections
LATE
NonUnion MalUnion Arthritis Joint stiffnes
TREATMENT SUPRACONDYLAR Fx.
CLOSED REDUCTION & INTERNAL FIXATION : RETROGRADE NAILING (RETRONAIL)
(+/- OPEN REDUCTION & INTERNAL FIXATION)
TREATMENT SUPRACONDYLAR Fx. RETROGRADE NAIL
TREATMENT SUPRACONDYLAR Fx.
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TREATMENT SUPRACONDYLAR Fx.
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TREATMENT SUPRA- AND INTERCONDYLAR Fx.
OPEN REDUCTION & INTERNAL FIXATION :
Plate and screws
DCS (Dynamic Condylar Screw) A.O. Blade - Plate
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TREATMENT SUPRA- AND INTRACONDYLAR Fx.
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TREATMENT SUPRA- AND INTRACONDYLAR Fx.
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TREATMENT SUPRA- AND INTRACONDYLAR Fx.
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TREATMENT SUPRA- AND INTRACONDYLAR Fx.
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TREATMENT UNICONDYLAR Fx.
ORIF : screws / plate and screws
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FRACTURES OF THE PATELLA
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Anatomy. Function
Largest sesamoid bone Part of the femoro patellar joint (posterior
aspect : articular surface divided into medial and lateral facets by longitudinal ridge; distal pole nonarticular
Part of the knee extensor mechanism
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MECHANISM OF INJURY
Direct / Indirect (avulsion)
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CLASSIFICATION
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Physical Examination
Pain, swelling, contusions, lacerations and/or abrasions at the site of injury Palpable defect Assessment of ability to extend the knee against gravity or maintain the knee in full extension against gravity
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TREATMENT GOALS
Restore extension function Restore articular congruency
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TREATMENT ALGORITHM
FRACTURE TYPE NonDisplaced ( Extension ) INDICATION Orthopedic
Displaced fractures
Inferior pole fx.
ORIF
Polar patelectomy + patellar td. reinsertion
Severe cominution, elderly Osteo-chondral fx.
Total patelectomy Excision / fixation
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ORTHOPEDIC TREATMENT
Long leg (femoro-tibial) cylinder cast for 4-6 weeks
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SURGICAL TREATMENT Tension Band Wiring
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COMPLICATIONS
Open fx. Infection Malunion Femoro-patellar arthritis Joint stifness Hardware failure
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TIBIAL PLATEAU FRACTURES
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Anatomy
Proximal Tibia widens into lateral and
medial tibial flares flares lead to medial and lateral plateau (condyles) intercondylar eminence tibial tubercle (patellar td.) Gerdys tubercle (ITB) proximal tib/fib joint
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Mechanism
Low energy trauma : valgus-stress (elderly) lateral plateau fx. High energy trauma : associated mechanisms (falls from height, MVA etc.) complex fx.
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Schatzker I Split type
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Schatzker III Depression type
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Schatzker II Split depression type
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Schatzker IV Medial condyle fr.
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Schatzker V Bicondylar fr.
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Schatzker VI Bicondylar fr. with physeal diaphyseal dissociation
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Physical examination
Painfull weight bearing Hemarthrosis (swelling, patelar shock present) Knee stability evaluation Vascular evaluation ( ! posteriorly displaced fragments) Neurologic evaluation (peroneal nerve) ! Compartment syndrome Blisters
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Computed Tomography
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Complications
IMMEDIATE
EARLY
Comp . Sdr.
LATE
MalUnion Arthritis Joint instability Joint stiffnes
Neuro-vasc injuries Blistering DVT Infections
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Treatment options
Nondisplaced (elderly) Orthopedic Treatment :
above the knee cast 6 8 weeks no weight bearing
Displacd : Surgical Treatment ORIF
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SURGICAL TREATMENT GOALS
RESTORE JOINT CONGRUITY
RESTORE JOINT STABILITY
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SURGICAL TREATMENT SCHATZKER I
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SURGICAL TREATMENT SCHATZKER III
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SURGICAL TREATMENT SCHATZKER II
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SURGICAL TREATMENT COMPLEX FRACTURES
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SURGICAL TREATMENT COMPLEX FRACTURES
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TIBIAL DIAPHYSEAL FRACTURES
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Introduction
492,000 per year (incidence) Injury mechanism (direct / indirect, high trauma) : MVA sport injuries falls gunshot injuries
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Physical Exam
Pain, inability to bear weight, and deformity may be seen
Local swelling and edema variable Careful inspection of soft tissue envelope necessary, including compartment swelling Thorough neurovascular assessment including motor/sensory exam and distal pulses
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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
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COMPLICATIONS
IMMEDIATE
Open fracture Neuro-vascular injuries
EARLY
Compartment sdr. Soft tissue problems Infection DVT
LATE
Delayed- / Nonunion Malunion
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Treatment
Surgical (apart from nondisplaced fx.) CRIF : centromedullary nails
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Open fractures
(~)
Gustilo Anderson classification
Criteria : - trauma energuy - soft tissue staus - bacterial contamination
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Open fractures
Type I
- low energy - wound ~ 1 cm. - minimal contamination
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Open fractures
Type II - medium energy - wound > 1 cm. - no devitalised tissues - medium contamination
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Open fractures
Type IIIA - high energiy - extensive lacerations and soft tissue devitaliation - important contamination - ! posible coverage of the fracture site
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Open fractures
Type IIIB -fracture site exposure, periostal stripping - gros contamination
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Open fractures
Type IIIC = type IIIB + arterial lesions
limb salvage procedures or amputation
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Open fractures
TREATMENT Issues = wound closure = fracture fixation
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Open fractures
TREATMENT WOUND = excision = debridement = fracture coverage * suture * flaps (* epitelisation per secundam) = ATPA, AB, antigangrenous serum
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Open fractures
TREATMENT Fracture fixation = intramedulary nails ( I, II, +/-IIIA?) = external fixation
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External fixation
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ANKLE FRACTURES (MALLEOLAR FRACTURES)
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Ankle Anatomy
Complex joint comprising the articulation of the tibia and fibula with the foot at the talus Intrinsic stability arises from congruous bony articulations and muscular forces across the ankle Extrinsic stability arises from the medial and lateral ligament complex and capsule Relatively thin soft tissue envelope
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MECHANISM OF INJURY
Indirect (complex abnormal rotation)
Inversion
Eversion
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RADIOLOGIC ASSESMENT
MORTISE VIEW (15 INT. ROT.) LATERAL VIEW
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Tibiofibular overlap
<10mm is abnormal implies syndesmotic injury
Tibiofibular clear space
>5mm is abnormal implies syndesmotic injury
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< 1 mm overlap
Medial joint space widening
Deltoid lig. injury
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CLASSIFICATION - DESCRIPTIVE
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Weber (Duparc) CLASSIFICATION
Weber C fibula proximal to mortise
Weber B fibula at level of mortise
Weber A fibula distal to mortise Concept - the higher the fibula the more severe the injury
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CLASSIFICATION
STABLE UNSTABLE : > 2 LESIONS TALAR DISLOCATION
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COMPLICATIONS
IMMEDIATE
OPEN Fx. (medial)
EARLY
Soft tissue problems Infections DVT
LATE
Nonunion Malunion Arthritis Ankle instability SRD
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TREATMENT OPTIONS
STABLE : orthopedic treatment UNSTABLE (Ist step repositioning of the talus) : Orthopedic treatment CR (talus perfecty centered) + Imob. or Surgical treatment : ORIF
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Orthopedic treatment
Reduction + XRay assesment
Above-the-knee cast 6 weeks
No weight bearing Weekly XRay reviews (Ist month)
Below-the-knee cast 4 weeks Progressive weight bearing
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Surgical treatment
Lateral maleollus : plate and screws Medial malleolus : screws / tension band wiring Posterior malleolus : screws Sindesmotic injuries : screws
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ANKLE FRACTURES (TIBIAL PLAFOND
FRACTURES)
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Introduction
Terrible Injuries (High Trauma)
Mechanism Axial Loading Severe soft tissue problems Excellent Results are rarely achieved Fair-Good results are the norm Treatment complications must be avoided
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Current Spectrum of Treatment Techniques
Spanning External Fixation Ext. fixation + Percut. screws
Internal Fixation with Plates and screws
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IF : Plate & Screws
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EF + percutaneous screws
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FRACTURES OF THE CALCANEUS
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Introduction
High potential for disability
Pain Gait disturbance Unable to work
Best treatment method controversial
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Anatomy
Calcaneocuboid
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Ant. Middle
Anatomy:
Facets of ST Joint
IO lig.
Post.
Tub.
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Hindfoot Function
Calcaneus Lever arm powered by gastrocnemius Foundation for body wt. Supports/ maintains lat. column of foot
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Classification
According to the involvement of the subtalar joint : Intraarticular fractures Extraarticular fractures
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Mechanism
Falling from some height
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Clinical presentation
Intense swelling Hindfoot deformity : decreased height / increased width / valgus deformity Early plantar echimosis Blistering, ischemia, skin necrosis ! Compartment syndrome
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Complications
Early : Soft tissue problems Compartment syndrome Wound healing problems / infection
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Complications
Malunion Stiffness
Loss of normal gait Shoewear problems Arthritic pain Sympathic Reflex Distrophy
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Imagistic assesment
lateral XRays + CT scan :
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CLASSIFICATION - BHLER
Bohlers Angle
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CLASSIFICATION - BHLER
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Orthopedic treatment
Indications : Non- or minimally displaced fractures CI to surgery :
soft tissue complications
diabetes peripheral vascular disease elderly, with severe medical problems severly cominuted fx. + inexperienced surgeon
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Orthopedic treatment
Below-the-knee (Graffin type) plaster cast for ~ 6 weeks
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Surgical treatment
Goals :
Restoring subtalar joint congruence Restoring height and orientation of the hindfoot
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Surgical treatment OR + grafting + IF
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Surgical treatment
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The End (Sfarsit)
The End
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