Presented by:
Dr. Aric Storck
October 2, 2002

Objectives
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Clinical evaluation
Radiological diagnosis
Emergency department management
Will not discuss hip fractures (femoral head, neck, trochanters) – discussed at pelvis/hip rounds
Will not discuss distal tib/fib fractures discussed during ankle rounds

Femur Fractures

Femur Fractures
Femoral Shaft Fractures
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High-energy trauma – MVC, bicycle, falls
Tensile strain usually produced transverse fractures
Comminution with higher forces
Open fractures uncommon – generally penetrating trauma
Pathologic fractures – result from torsional stress causing spiral fracture

Femoral Shaft Fracture
Classification
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No generally accepted system
Describe based on characteristics
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Location
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Geometry
Transverse, oblique, spiral, wedge, comminution

Femoral Shaft Fractures

Femoral Shaft Fractures
Clinical Features
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Obvious deformity
50% have ligamentous instability of the knee
Neurovascular injuries rare in closed fractures
Fracture of Proximal 2/3
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Proximal fragment abducted, flexed, and externally rotated due to pull of gluteal and iliopsoas muscles of trochanters
Fracture of Distal 1/3
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Hyperextension of distal fragment due to pull of gastrocnemius

Femoral Shaft Fractures
ED Management
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Cross and type for at least 2 units PRBC
Assess and treat neurovascular status
D/C traction (NV damage more likely from traction than from fracture)
Immobilize without traction
Analgesia (im/iv or femoral nerve block with bupivicaine after careful neurological exam)

Femoral Shaft Fractures
Definitive Management
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Traction
 no longer commonly employed
External fixation
 especially open and comminuted fractures
Intramedullary rods
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Operation of choice for most fractures
Has been shown to decrease hospitalization and total disability

Femoral Shaft Fractures
Definitive Treatment
Callus formation 3 weeks post IM nail
Bridging trabeculae 5 weeks post IM nail

Femoral Shaft Fractures
Complications
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Outcome generally good with close to 100% union rate. Potential complications include…
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Malunion
Fat embolism
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2-23% of isolated femoral shaft fractures
Fever, tachycardia, ALOC, resp distress, petechiae
ARDS
Hemorrhage (average 1-1.5 litres)
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Concurrent multisystem trauma
Limb-length discrepancy
Compartment syndrome of the thigh - rare

Knee Fractures
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Distal Femur
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Supracondylar
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Intracondylar
Condylar
Patella
Proximal Tibia
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Tibial plateau
Tibial spine

Ottawa Knee Rules
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1.
2.
X-ray knees with knee injury and one or more of:
Blunt knee trauma in a patient >55 years old
Tenderness to palpation of head of fibula
3.
4.
5.
Isolated tenderness of patella
Inability to flex knee to 90 degrees
Inability to bear weight both immediately and inability to take four steps in ED

Exclusion criteria
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Isolated skin injuries
Referred patients from another ED or clinic
Injury >7 days old
Patient returning for re-evaluation
Distracting injuries
Altered mental status
Age < 18 years old
Pregnant patients
Paraplegia

Ottawa Ankle Rules
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Derived from study of 1047 adult ankle injuries
100% sensitive
54% specific
Reduced radiography from 69% – 49%
Reduced time in ER by 39 minutes
Stiell IG, Greenberg GH, Wells GA, et al: Prospective validation of a decision rule for the use of radiography in acute knee injuries . JAMA 275:611-615, 1996
Stiell IG, Wells GA, Hoag RH, et al: Implementation of the
Ottawa knee rule for the use of radiography in acute knee injuries . JAMA 278:2075-2079, 1997

Knee Injuries
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If Ottawa criteria are met x-ray:
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AP / Lateral
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“sunrise” view for patients with patellar tenderness
Oblique view / plateau view for patients unable to bear weight
 provides better view of femoral condyles, tibial tuberosity, medial/lateral patellar margins
Tunnel view for patients with suspected ACL injury and tibial spine fracture

Pittsburgh Rules for Knee
Radiographs

Pittsburgh Rules for Knee
Radiographs
Exclusion criteria
• Injury >6 days old
• Isolated skin injuries
• History of knee fracture or surgery
• Repeat visit for same injury

Pittsburgh vs Ottawa rules
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More specific than Ottawa rules (60-
80% vs 27-49%)
Comparable sensitivity (99% vs 97%)
One study found the Pittsburgh rules decreased knee radiography by 52% with one missed fracture vs 23% with three missed fractures
Seaberg DC, Yealy DM, Lukens T, et al: Multicenter comparison of two clinical decision rules for the use of radiography in acute, high-risk knee injuries . Ann
Emerg Med 32:8-13, 1998

Distal Femoral Fractures

Distal femur fractures
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Uncommon
Result from high velocity trauma (MVC)
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Hyperabduction
Adduction
Hyperextension
Axial loading
Extensive soft tissue injuries
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Compartment syndrome - rare

Distal femur fractures
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Examination
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Knee pain deformity hemarthrosis
Supracondylar fractures
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Shortened and externally rotated thigh
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Quadriceps pull proximal fragment forwards
Gastrocnemius pulls distal fragment back

Femur fractures - imaging
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AP
Lateral
Also don’t forget …
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AP pelvis
AP/lateral hip

Distal Femur Fractures
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Anatomy
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Vascular
 close to femoral/popliteal vessels
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Assess distal pulses
Palpate for hematoma in popliteal fossa
Neurological
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Tibial nerve – gastrocnemius, plantaris
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Peroneal/Deep Peroneal nerves
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Supplies anterior compartment (dorsiflexion)
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Sensory to first dorsal interosseus cleft

Distal Femur Fractures
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Supracondylar
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Extra-articular
No hemarthrosis
Intracondylar
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Intra-articular
Condylar
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Intra-articular

Distal Femur Fractures

Distal Femur Fractures
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No definitive classification system
Evaluate based on
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Displacement
Comminution
Soft-tissue injury
Neurovascular status
Joint involvement
Intra vs extra-articular
Open vs closed

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Distal Femur Fractures
Complications – similar to femoral shaft
 dvt
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 fat embolism delayed union / malunion valgus/varus deformities chronic arthritis compartment syndrome growth disturbances in adolescents (65% of leg growth from distal femoral epiphysis!!)

Distal Femur Fractures
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Management
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 assess & manage neurovascular status analgesia (consider femoral nerve block) immobilization appropriate fluid management orthopedic referral
 definitive treatment (ORIF vs conservative)

Distal Femur Fractures

Distal Femur Fractures

Distal Femur Fractures

Distal Femur Fractures
Transcondylar fracture 10 months post ORIF

Distal Femur Fractures

Patellar Fractures
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Largest sesamoid bone in body
Acts to increase mechanical advantage during knee extension
1% of all adult fractures
27% occur during MVC’s – knee to dash
Most patellar fractures are intra-articular
Search for concomitant injuries
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Knee/acetabular dislocations
Acetabular fractures
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Femur fractures

Patellar fractures - mechanism
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Indirect trauma
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Forceful knee flexion against contracted quadriceps
Horizontal fractures common
Direct trauma
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Direct blow / fall on knee comminution

Patellar fractures

Patellar fractures - Px
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Pain
Hemarthrosis
Crepitus
Disruption of extensor mechanism
(must be able to fully extend knee against gravity)

Patellar fractures
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Imaging
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AP
Lateral
Sunrise
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Tangential view across 45 degree flexed knee
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Shows small vertical fractures of patella

Transverse Patellar Fracture

Patellar fractures -
Management
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Nondisplaced with intact extensor mechanism
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 immobilize knee in extension with partial weight bearing x 3 weeks
Repeat x-ray in 3 weeks
Wear another 3 weeks for horizontal fractures, less for vertical fractures

Patellar Fractures
Management
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Displaced (>3mm bony separation or >
2mm articular surface disruption)
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Orthopedic referral
Tension band / K-wires
Possible patellectomy – surgical connection of quadriceps and patellar tendons

Patellar Fractures
58 year old dashboard injury and comminution of patella

Patellar Fractures
After total patellectomy and repair of the extensor mechanism

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Major load-bearing structure of lower leg
Thin overlying tissues
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 open fractures common
Easily fractured by direct trauma

Tibial Plateau Fractures
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 aka tibial condylar fracture
Mechanism - can be almost any …
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 axial compression rotation
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 direct trauma varus/valgus stress
Trivial mechanism in osteoporotic individuals
Very common after pedestrian vs automobile
– due to valgus/varus stress

Tibial Plateau Fractures
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Examination
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Unable to weight bear knee slightly flexed
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 knee effusion
Joint line pain possible varus/valgus deformity (esp. with depressed fractures) associated ligamentous and meniscal injuries assess neurovascular status

Tibial Plateau Fractures
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Imaging
 if meets Ottawa rules
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AP
 lateral (medial condyle concave, lateral condyle convex)
 if patient unable to weight bear 4 steps
 oblique views
 tibial plateau view (AP with 15 deg vertical orientation)

I.
II.
III.
Schatzker Classification of tibial plateau fractures
1. Lateral plateau fracture without articular depression
2. Lateral plateau fracture with articular depression
3. Isolated areas of lateral plateau depression
NB: 60% are lateral plateau fractures (types I-III)

Tibial Plateau Fractures
Schatzker Classification

Schatzker Classification
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4. Medial plateau fracture (15%)

Schatzker Classification
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5. Bicondylar
NB: 25% of fractures bicondylar (types V-VI)

Schatzker Classification
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6. Bicondylar & tibial shaft
NB: 25% of fractures bicondylar (types V-VI)

Tibial Plateau Fracture. Type?

Tibial Plateau Fracture. Type?

Tibial Plateau Fracture - Type?

Tibial Plateau Fractures
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Management
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I-III can be managed by experienced primary care physician
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Splint in extension
Non-weight bearing x 4-6 weeks
III-VI require orthopedic assessment
Decision to operated based on:
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Ligament/fracture stability
Displacement >3mm
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Comminution
Fracture location age

Tibial Plateau Fractures
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Complications
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 decreased ROM degenerative arthritis angular deformity of knee associated ligamentous injuries neurovascular compromise early and late
(compartment syndrome)

Neurovascular compromise in action
Popliteal artery occlusion following high energy bicondylar tibial plateau fracture

Schatzker type II and proximal fibular fracture

Tibial Spine Injuries
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 aka intercondyle eminence
Same mechanism as ACL rupture
(hyperextension, rotation, ab/adduction)
In young patients ACL stronger than tibial spine – thus tibial spine injury
Suspect with ACL-like presentation
(positive Lachman, etc.) AND inability to weight bear

Tibial Spine Injuries
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Type I
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Incomplete avulsion with no displacement
Type II
 incomplete avulsion with displacement
Type III
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Completely avulsed fragment

Tibial Spine Injury
Type II tibial spine avulsion fracture

Tibial Spine Injuries Treatment
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Orthopedic referral for all
Type I/II
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Attempt closed reduction with hyperextension
Immobilize x 4-6 weeks in extension
Type III
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ORIF

Tibial Tuberosity Fractures
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Forced flexion vs. contracted quadriceps
Uncommon after apophysis closure

Tibial Tuberosity Fractures
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Type I
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Distal fragment displaced proximally and anteriorly
Type II
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Fragments hinged at proximal portion
Large fragment extending into physis
Type III
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Extension into articular surface

Tibial tuberosity fractures
Type II tibial tuberosity fracture

Tibial Tuberosity Fractures
Treatment
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Type I
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Immobilization in extension x 6 weeks
Type II/III
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Orthopedic referral for ORIF

Tibial Shaft Fracture
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Most commonly fractured long bone
Commonly open (1/3 of surface area just subcutaneous)
Precarious blood supply
Hinge joints at knee and ankle are unforgiving of post-reduction deformity

Tibial Shaft Fractures
Classification
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No universally accepted classification scheme.
Describe the following
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Location (prox, middle, distal third)
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Configuration (transverse, spiral, comminuted)
Displacement
Angulation
Length rotation

Tibial Shaft Fracture
Closed distal third comminuted fracture of left tibia
Nondisplaced as <5% angulation, no rotation

Tibial Shaft Fracture
ED Treatment
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Manage neurovascular status
Carefully inspect any soft tissue defect for open fracture
Splint in long-leg, padded, posterior splint
Beware of compartment syndrome

Tibial Shaft Fracture
Definitive Management
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Orthopedic referral
No consensus exists re: definitive treatment
Multifactorial decision
Possible management
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ORIF
Intramedullary rod
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Cast immobilization
Early progressive weight bearing after two weeks

Tib/Fib Fractures

Fibular Fractures
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Not significantly involved in weight bearing
Usually associated with tibial fractures
Important in stability of knee/ankle
Proximal fibula = attachment site of LCL and biceps femoris
Beware of peroneal nerve injuries
Patients can often walk on isolated fibular fractures

Fibular Shaft Fractures
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Direct force
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Blow to leg
Transverse or comminuted fracture
Indirect force
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Rotational – oblique fracture
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Varus stress – avulsion injury

Fibular Shaft Fractures
Imaging
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AP / lateral – generally sufficient
Always order knee / ankle x-rays
NB: common association with tibial plateau fractures (type II)

Fibular Shaft fractures
Treatment
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Immobilization in posterior splint
Non-weight bearing until follow-up visit. Weight bearing afterwards
NB: always generously pad fibular head during casting to avoid peroneal nerve injury
Treatment of tibial fracture generally treats fibular fracture as well
ORIF generally reserved for stabilization of complex concurrent tibial injuries