Lower Extremities Fractures (Part I)

Dr. Apoorv JainD’Ortho, DNB Ortho

drapoorvjain23@gmail.com+91-9845669975

• Pelvic Fractures• Fracture Neck Of

Femur• Intertrochanteric

Fracture Femur• Fracture Shaft Of

Femur

Pelvic Fractures

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

The pelvic brim is formed by the arcuate lines that join the sacral promontory posteriorly and

the superior pubis anteriorly.

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

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

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

• 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

• 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.

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

• 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

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

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

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

• 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

Classifications

Young-Burgess classification

AP Compression Type

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

• Operative Techniques–External fixation –Internal fixation

• Open reduction and stable internal fixation are performed using lag screws and neutralization plates.

Complications• Infection• Thromboembolism:

– Disruption of the pelvic venous vasculature and immobilization constitute major risk factors for the development of deep venous thromboses.

• Malunion• Nonunion

Fractures Around Hip

• Includes:–Acetabular Fractures–Fracture Head Of Femur–Fracture Neck Of Femur–Intertrochanteric Fracture Femur

Frequently Associated With Hip Dislocation

Fracture Neck Of Femur

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

• 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)

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.

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

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

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

Technetium Bone Scan or preferably Magnetic resonance imaging may be used to identify undisplaced or occult fractures that are not apparent on plain radiographs

Classification• Anatomic Location

– Subcapital– Transcervical– Basicervical (Treated as ExtraCapsular)

Treated as IntraCapsular

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

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

Treatment Algorithm(for fracture neck of Femur)

Undisplaced

Displaced

Hemiarthroplasty/Total Hip Arthroplasty

OldYoung

Percutaneous Screw or Arthroplasty

PercutaneousCancellous Screw

Open Reduction &Internal Fixation

Internal Fixation For Fracture Neck Of Femur (For Younger Patients)

Percutaneous Cancellous Screw Fixation

Fixation With a DHS and Derotation Screw

Elderly Patients(Physiological age>60 years)

Hemireplacement Arthroplasty

Total Hip Replacement

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

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

• 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

• 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+

Intertrochanteric Fracture Femur

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

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.

• Deforming muscle forces will usually produce– Shortening– Abduction of proximal femur– Medial displacement, Adduction and proximal

migration of distal femur

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

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)

• 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

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.

Fracture stability depends on the integrity of the Posteromedial bony cortex

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

Stable Fracture Pattern with Intact/ Minimally comminuted Posteromedial

Cortex

Unstable Fracture Pattern with,Greater comminution of Posteromedial

cortexReverse Oblique FracturesSubtrochanteric Extension

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

Dynamic Hip Screw (Sliding hip screw)

Intramedullary Fixation

Complications

• Loss Of Fixation• Malunion (Usually malrotation, varus/valgus)• Non Union (Very rare, <2%)• Infection• Osteonecrosis Of femoral head (Rare)

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

Fracture Shaft Of Femur

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

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

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

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

• 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

Thomas Splint Immobilisation before shifting the patient

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

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

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

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

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

For patients in whom surgery needs to be delayed, temporary stabilisation with

Skeletal traction is required

Fixation Options

• Intramedullary Fixation• Open Reduction and Plate Fixation• External Fixation

(For Open/ Infected Fractures)

Intramedullary Fixation

Plate Fixation

External Fixation

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

Pavlik Harness for Age<6months

Hip Spica Castfor Age upto 5 years

Gallows Traction

PaediatricThomas Splint

Flexible Intramedullary Nail Fixation

• 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

Complications• Neurovascular injury• Complartment Syndrome• Infection• Fixation Failure• Non-Union/ Delayed Union• Malunion• Heterotopic Ossification

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