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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