Femur and Tibia Fractures
Kevin E. Coates, M.D., M.P.T.
Worker’s Compensation?
2
Femoral Neck Fractures
• Epidemiology
• 250,000 Hip fractures annually
– Expected to double by 2050
• At risk populations
– Elderly: poor balance&vision, osteoporosis, inactivity,
medications, malnutrition
• incidence doubles with each decade beyond age 50
– higher in white population
– Other factors: smokers, small body size, excessive
caffeine & ETOH
– Young: high energy trauma
3
Classification
•
Garden
•I Valgus impacted or
•
incomplete
•II Complete
• Non-displaced
•III Complete
• Partial displacement
•IV Complete
• Full displacement
•** Portends risk of AVN and
Nonunion
I
II
III
IV
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Treatment
• Goals
– Improve outcome over natural history
– Minimize risks and avoid complications
– Return to pre-injury level of function
– Provide cost-effective treatment
5
Treatment
Decision Making Variables
• Patient Characteristics
– Young (arbitrary physiologic age < 65)
• High energy injuries
– Often multi-trauma
– Elderly
• Lower energy injury
• Comorbidities
• Pre-existing hip disease
6
Treatment
Young Patients
(Arbitrary physiologic age < 65)
– Non-displaced fractures
• At risk for secondary displacement
• Urgent ORIF recommended
– Displaced fractures
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•
•
•
Patients native femoral head best
AVN related to duration and degree of displacement
Irreversible cell death after 6-12 hours
Emergent ORIF recommended
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Hemi
ORIF
THR
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Non-displaced Fractures
• ORIF standard of care
• Predictable healing
– Nonunion < 5%
• Minimal complications
– AVN < 8%
– Infection < 5%
• Relatively quick procedure
– Minimal blood loss
9
Displaced Fractures
Hemiarthroplasty vs. ORIF
• ORIF is an option in elderly
Surgical emergency in young patients
• Complications
• Nonunion 10 -33%
• AVN 15 – 33%
• AVN related to displacement
• Early ORIF no benefit
• Loss of reduction / fixation failure 16%
10
Displaced Fractures
Hemiarthroplasty vs. ORIF
• Hemi associated with
•
•
•
•
•
Lower reoperation rate (6-18% vs. 20-36%)
Improved functional scores
Less pain
More cost-effective
Slightly increased short term mortality
11
Femoral Neck
Nonunion
•
•
•
•
Definition: not healed by one year
0-5% in Non-displaced fractures
9-35% in Displaced fractures
Increased incidence with
– Posterior comminution
– Initial displacement
– Inadequate reduction
– Non-compressive fixation
12
Femoral Neck Fractures
Complications
• Failure of Fixation
– Inadequate / unstable reduction
– Poor bone quality
– Poor choice of implant
• Treatment
– Elderly: Arthroplasty
– Young: Repeat ORIF
Valgus-producing osteotmy
Arthroplasty
13
Femoral Neck Fractures
Complications
• Post-traumatic arthrosis
• Joint penetration with hardware
• AVN related
• Blood Transfusions
– THR > Hemi > ORIF
– Increased rate of post-op infection
• DVT / PE
– Multiple prophylactic regimens exist
• One-year mortality 14-50%
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Intertrochanteric Femur Fractures
• Intertrochanteric
Femur
– Extra-capsular
femoral neck
– To inferior border of
the lesser trochanter
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Etiology
• Osteoperosis
• Low energy fall
– Common
• High Energy
– Rare
16
Radiographs
• Plain Films
– AP Pelvis
– Cross Table
Lateral
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Goals of Treatment
• Obtain a Stable Reduction
• Internal Fixation
– Good Position
– Mechanically Adequate
• Permit Immediate Transfers & Early Ambulation
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Rehabilitation
• Mobilize
– Weight Bearing As Tolerated
– Cognitive Intact Patients Auto Protect
– Unstable Fractures = Less WB
– Stable Fractures = More WB
• No Difference @ 6 weeks Post op
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Femoral Shaft Fractures
•
•
•
•
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Common injury due to major violent trauma
1 femur fracture/ 10,000 people
More common in people < 25 yo or >65 yo
Femur fracture leads to reduced activity for 107 days
Motor vehicle, motorcycle, auto-pedestrian, aircraft,
and gunshot wound accidents are most frequent
causes
20
Femur Fracture
Management
• Initial traction with portable traction splint or
transosseous pin and balanced suspension
• Evaluation of knee to determine pin placement
• Timing of surgery is dependent on:
– Resuscitation of patient
– Other injuries - abdomen, chest, brain
– Isolated femur fracture
21
Femur Fracture
Management
• Antegrade nailing is still the gold standard
• Antegrade nailing problems:
– Varus alignment of proximal fractures
– Trendelenburg gait
– Can be difficult with obese or multiply injured patients
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Femur Fracture
Management
• Retrograde nailing has advantages
– Easier in large patients to find starting point
– Better for combined fracture patterns (ipsilateral
femoral neck, tibia,acetabulum)
• Retrograde nailing has its problems:
– Intra-articular starting point
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Femur Fracture
Complications
•
•
•
•
•
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Hardware failure
Nonunion - less than 1-2%
Malunion - shortening, malrotation, angulation
Infection
Neurologic, vascular injury
Heterotopic ossification
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Ipsilateral Femoral Neck & Shaft
Fractures
• Optimum fixation of the femoral neck should be the
goal
• Varus malunion of the femoral neck is not
uncommon, osteotomies can lead to poor results
• Vertical femoral neck fracture seen in 26-59% of cases
• Rate of avascular necrosis is low, 3%, even when
missed
25
Tibial Plateau Fractures
• Mechanism of Injury
• Mean age in most series of tibial plateau
fractures is about 55 years
– Large percentage over age 60
• Elderly population is increasing in numbers
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Mechanism of Injury
• Mechanism of injury is fall from standing
height in most patients
– MVA is increasing as % of fractures
• Most common fracture pattern is splitdepressed fracture of lateral tibial plateau
(80% of fractures)
27
Physical Exam
• Neurologic exam
– peroneal nerve!
• Vascular exam
– popliteal artery and medial plateau injuries
– beware the of the knee dislocation posing as a
fracture
– beware of posteriorly displaced fracture
fragments
– ABI <0.9 urgent arterial study
28
Physical Exam
• Compartment syndrome
• KNEE STABILITY
– varus/valgus in full extension
– may require premedication
• aspiration of knee effusion/hematoma
• replace with lidocaine+marcaine
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Evaluation of Soft Tissues
• Proximal and distal
tibia subcutaneous
• Soft tissue remains
compromised for at
least 7 days
• Early ORIF risks wound
slough exposed
hardware
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AP and Lateral Radiographs
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Pre-traction
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Post-traction
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Computed Tomography
• Indications
– Fracture in an active patient for which you are
considering nonsurgical care
– Complex fracture
– To aid surgical planning of approach, technique,
screw position, etc.
34
Computed Tomography
35
Computed Tomography
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Classification:
Schatzker
I
III
II
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Classification:
Schatzker
IV
VI
V
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Surgical Indicatons
• Open Fracture – I&D, spanning ex-fix
• Extensive soft tissue contusion – spanning ex-fix
• Closed fracture
– Varus/valgus instability of the knee
– Varus or valgus tilt of the proximal tibia
– Meniscal injury/previous mensicectomy
– Articular displacement or gapping???
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Angular Malalignment of the
Proximal Tibia
– Incidence of arthrosis:
• Valgus < 10o
• Valgus > 10o
14%
79%
• Any amount of varus angulation was bad
• Independent of articular congruity
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Meniscectomy
– Higher rate of arthrosis in patients who had undergone meniscectomy at surgery
– 70% arthrosis in patients who had undergone meniscectomy
– results independent of the amount of articular incongruity
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Postoperative Management
• Immediate PROM/AROM of knee
• Routine Pin site care (if ex-fix)
• TDWB for 8-12 weeks
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Outcomes
• Outcome depends on:
– Varus valgus stability of the knee
– Varus/valgus alignment of the proximal tibia
– Presence of an intact meniscus
– Articular congruity (to a lesser extent)
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Treatment Goals
• Focus on restoring stability and proximal tibial
alignment to the knee, rather than restoring anatomic
alignment of the articular surface at all costs
• Use minimally invasive techniques, when possible
• Other techniques are preferable to hybrid ex-fix
• MOVE THE KNEE EARLY IN ALL PATIENTS!
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Tibial Shaft Fractures
Mechanism of Injury
● Can occur in lower energy, torsional type injury (eg, skiing)
● More common with higher energy direct force (eg car bumper)
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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
46
Associated Injuries
• Up to 30% of patients with
tibial fractures have
multiple injuries*
• Fracture of the ipsilateral
fibula common
• Ligamentous injury of
knee common in high
energy tibia fractures
47
Associated Injuries
• Ipsilateral femur fx, so called
“floating knee”, seen in high
energy injuries
• Neuro/vascular injury less
common than in proximal
tibia fx or knee dislocation
• Foot and ankle injury should
be assessed on physical exam
and x-ray if needed
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Compartment Syndrome
• 5-15%
• History of high energy or
crush injury
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Nerve is the Tissue most Sensitive
to Ischemia
• PAIN first Symptom
• PAIN with Passive Stretch first Sign
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Each Compartment
has Specific Innervation
•
•
•
•
Ant Comp Deep- - Peroneal
Lateral -Sup Peroneal N.
Deep Post. - Tibial N.
Sup Post. - Sural N.
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Advantages of IM Nail
• Advantages include less
malunion and less
shortening than closed
treatment or ex-fix
• Earlier weight bearing
may be allowed with
insertion large nail
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• Proximal Fractrues are technically more challenging
• Prone to Valgus & Pro-curvatum deformities
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Complications
• Infection 1-5%
• Union >90%
• Knee Pain
Common
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Knee Pain
• Severe
9%
• Moderate 22%
• Mild
68%
• Kneeling 92%
• Running 57%
• Rest 37%
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Nail Removal
• Resolved 27%
• No - 20%
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Disadvantages of IM Nail
• Disadvantages include anterior knee pain (up
to 56.2% *), risk of infection
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External Fixator
• External fixation
generally reserved
for open tibia
fractures or
periarticular
fractures
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Disadvantages of External Fixator
• Increased incidence of malunion compared to
IM nail
• Risk of pin tract infection, cellulitis
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Outcomes of External Fixation
• 95% union rate has been reported for group of closed and
open tibia fractures, but 20% malunion rate*
• Most common complications are pin track infections and
malunion
• Loss of reduction associated with removing frame prior to
union
61
Open Tibia Fractures
● Open fractures of the tibia
are more common than in
any other long bone
● Rate of tibial diaphysis
fractures reported from 2
per 1000 population to 2 per
10,000 and of these
approximately one fourth are
open tibia fractures*
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Associated Injuries
● Neurovascular structures
require repeated assessment
● Foot fractures also common
● Compartment syndrome
must be looked for
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Gustilo and Anderson Classification
● Grade 1- skin opening of 1cm or less, minimal muscle
contusion, usually inside out mechanism
● Grade 2- skin laceration 1-10cm, extensive soft tissue
damage
● Grade 3a- extensive soft tissue laceration(10cm) but
adequate bone coverage
● Grade 3b- extensive soft tissue injury with periosteal
stripping requiring flap advancement or free flap
● Grade 3c- vascular injury requiring repair
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Objectives
 Prevent
Sepsis
 Union
 Function
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Soft Tissue Coverage
● Definitive coverage should be performed within 7
days if possible
● Most type 1 wounds will heal by secondary intent or
can be closed primarily
● Delayed primary closure usually feasible for type 2
and type 3a fractures
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Soft Tissue Coverage
● Type 3b fractures require
either local advancement or
rotation flap, split-thickness
skin graft, or free flap
● STSG suitable for coverage of
large defects with underlying
viable muscle
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Soft Tissue Coverage
● Proximal third tibia fractures
can be covered with
gastrocnemius rotation flap
● Middle third tibia fractures
can be covered with soleus
rotation flap
● Distal third fractures usually
require free flap for coverage
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Amputation
● In general amputation
performed when limb
salvage poses significant risk
to patient survival, when
functional result would be
better with a prosthesis, and
when duration and course of
treatment would cause
intolerable psychological
disturbance
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Complications
● Nonunion
● Malunion
● Infection- deep and superficial
● Compartment syndrome
● Fatigue fractures
● Hardware failure
70
Nonunion
● Time limits vary from 6
months to one year
● Fracture shows no radiologic
progress toward union over
3 month period
● Important to rule out
infection
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Malunion
● In general varus malunion
more of a problem than
valgus
● For symptomatic patients
with significant deformity
treatment is osteotomy
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Deep Infection
● Often presents with
increasing pain, wound
drainage, or sinus formation
● Treatment involves
debridement, stabilization
(often with ex-fix), coverage
with healthy tissue including
muscle flap if needed, IV
antibiotics, delayed bone
graft of defect if needed
73
Superficial Infection
● Most superficial infections respond to elevation of
extremity and appropriate antibiotics (typically gram
+ cocci coverage)
● If uncertain whether infection extends deeper and/or
it fails to respond to antibiotic treatment, then
surgical debridement with tissue cultures necessary
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Hardware Failure
● Usually due to delayed union
or nonunion
● Important to rule out
infection as cause of delayed
healing
● Treatment depends on type
of failure- plate or nail
breakage requires revision,
whereas breakage of locking
screw in nail may not require
operative intervention
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Outcomes
● Outcome most affected by severity of soft tissue and
neurovascular injury
● Most studies show major change in results between
type 3a and 3b/c fractures
● For type 3b and 3c fractures early soft tissue coverage
gives best results
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Tibial Plafond Fractures
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Terrible Injuries
“Excellent Results” rarely achieved
Fair to Good Results are the Norm
Outcomes are Impossible to Predict
Avoid Treatment Complications
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Treatment Principles
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Delay Until Definitive Surgery
Spanning External Fixation
Pecutaneous and Limited Approaches
Plating Fibula
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Surgical Delay with External
Fixation
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Maintains Length and Aligment
Better Imaging Studies
Allows Mobilization
Pre-Operative Planning
Allows Soft Tissue Recovery
85
Plating of Fibula Fracture
• Fibular length
• Articular reconstruction
• Early motion
86
Outcomes
• Most Have Some Pain
• Most Return to Work
• Detectable Arthritis in 50%
87
Outcomes - Pain
• 50% Minimal
• 35% Pain with WB
• 15% Continuous
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Long Term Outcome
• 5 - 11 Years
• Most Have Some Degree of Ankle Pain
• Most Cannot Run or Play Sports
• 70% with Moderate to Severe Arthritis
• Most Rate Their Outcome as Good
89
Summary
• Bad Injuries with Unpredictable Outcomes
• Complications in 10% or Less
• Results Generally not Great but not Bad if no
Complications
90