Dr Tarif Alakhras
Orthopedic surgeon
kfmc
Common lower limb fracture
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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 Ligamentum Teres
• 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
• Intertrochanteric and
subtrochanteric fractures
do not involve the neck of
femur
Hip fracture
Capsule
Area
femoral head
Subcabital
Intracapsular
femoral neck
Transcervical
Basicervical
Intrtrochanteric
Extracapsular
subtrochanteric
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 ligamentous
stability (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
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
o
varus/valgus plane< 5
• Angulation in anteroo
posterior plane <10
• 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
o
Foot in 15 of
internal rotation
Ankle fracture
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
Bimalleolar feactur
Maisonneuve fracture.
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