GROUP 8

FRACTURE RELATED TO
FEMUR AND TIBIA
BY – Farina
AKSHAY
FATIMA
ANNAPOORANI
YUVRAJ
M. ATIF
ORTHOPEDICS
FEMORAL
FRACTURES
FARINA
 ANATOMY
 Strongest ,Longest and largest
bone in human
 Adult Male 48cm(l) & 2.4cm (d)
 30 x weight of body
 Proximal –hip joint
 Distal-knee joint
 Head
 Mid , distal, proximal (1/3)
 Mid-distal , proximal-mid
CLASSIFICATION
PIPKIN CLASSIFICATION OF FEMORAL HEAD #
• Femur head
FEMORAL NECK #
FEMORAL NECK FRACTURE CLASSIFICATION
CLASSIFICATION OF FEMORAL SHAFT #
 MECHANISM OF
INJURY
AKSHAYA MAURYA
 MECHANISM OF INJURY
• Twisting injury while walking, running.
• During certain activities such as landing from a jump,
stressed is placed on tibia and fibula.
• Abduction, adduction or external rotation forces
• Sports involving sudden change of direction such as
football, soccer, rugby , basketball, and netball.
FEMORAL SHAFT FRACTURES
• Direct trauma
RTA, fall, or child abuse
• Indirect trauma
Rotational injury
• Pathologic fractures
Osteogenesis imperfecta, nonossifying fibroma, bone cysts, and
tumors.
 COMPLICATIONS OF FRACTURES
• Early complication :
Vascular injury
Nerve injury
Compartment syndrome
Fracture blister
• Late complication :
Delayed/Non-union
Malunion
Avascular necrosis
Growth disturbance
Stiffness, post traumatic osteoarthritis,etc 18
 FEMORAL SHAFT FRACTURES
COMPLICATIONS
Outcome generally good with close to 100% union rate.
Potential complications include…
Malunion
Fat embolism
ARDS
Hemorrhage
Concurrent multisystem trauma
Limb length discrepancy
 MANAGEMENT OF
FRACTURE OF NECK
OF FEMUR
 Conservative Treatment
 Fractures at this level have a poor capacity for union due to the
following factors.
 Interference with the blood supply to the proximal fragment.
 Difficulty in controlling the small proximal fragment.
 The lack of organization of the fracture hematoma due to the
presence of the synovial fluid
 Two essential principles to be followed in the surgical
management of this fracture are
 (a) perfect anatomical reduction.
 (b) rigid internal fixation.
 The earlier method of stabilizing the fracture was by internal
fixation with Smith Petersen Trifin nail. The fracture is
reduced by manipulation with the patient in a special
orthopedic table. The fracture is internally fixed with an S.P.
Nail under radiological control. The more recent method of
internal fixation of the fracture is the use of multiple
compression screw
 In older patients above 60 years, such fractures are treated by
removing the head of the femur and replacing it by metal
prosthesis like Austin Moore's prosthesis. This enables the
patient to be ambulant and start early weight bearing.

 Fracture neck of femur in Children The fracture is reduced by

manipulation and the leg immobilized in full plaster spica in
abduction for 8-10 weeks. When indicated internal fixation
could be done with multiple thin Austin Moore's Pin
 Dynamic Hip Screw
 Most commonly used device for
both stable and unstable fracture
patterns.
 Plate angle is variable 130 to 150
degrees.
 Has to be positioned centrally in
the femoral head.
 Use of radiological views to know
the exact position.
 Austin Moore's  Total hip joint
prosthesis Replacement
Broad treatment guidelines
 Age group undisplaced Displaced

 More than 70 years DHS Prosthesis ,THR

 Young adults DHS DHS ,Osteotomy or
prosthesis
 Children HIP spica Multiple Moore`s
pinning,
Osteotomy,
arthrodesis.

 DHS = dynamic hip screws • THR = total hip replacement

 MANAGEMENT OF FRACTURE OF
FEMORAL SHAFT
Conservative method
 Traction and bracing(Thomas splint, perkins traction)
 Hip spica
 Gallow’s traction(in children from birth to 2 years)
Operative method
o Open reduction and plating .
o Closed interlock nailing
o Kuntscher”s clover leaf Intramedullary nailing (k-nail) External fixation
o Titanium elastic nail system(TENS)
 Traction and bracing : Traction with a splint is first aid
for a patient with a femoral shaft fracture.
Indication :
 fracture of children .
 contraindication to anesthesia .
 lack of suitable skills for internal fixation .
Length of time spent in bed is about 10 – 14 weeks .

Methods :
 Thoma’s splint
 Perkin’s traction
Thoma’s splint
This method rarely used because it lead to knee stiffness.
 PERKIN’S TRACTION
 Skeletal traction without splints.
The traction is applied directly on the bone by inserting a k- wire or
stienmen’s pin through the bone.
 Hip spica
 This is a plaster cast incorporating part of trunk and the limb.
It may be a single spica or one-and-half.
It can be safely used for immobilising these fractures in children.
It may also be used for treating fractures in young adults,once the fracture
becomes”sticky”.
 Gallow’s traction
 Fracture of children from birth to 2 years are treated.
 In this,the legs of the child are tied to the overhead beam.
The hips are kept a little raised from the bed so that the
weight of the body provide counter traction and fracture is
reduced.
 This is continued till sufficient callus forms(3-6weeks).
 Open reduction and plating : Internal fixation with plate
and screws .
Indications :
1- combination of shaft and femoral neck fracture .
2- fracture associated with vascular injury .
Intramedullary nailing : Is the method of choice and mostly
used . Implantation of intramedullary nail and fixed by screws
which is inserted transversely at proximal and distal ends .
The implantation of intramedullary nail may be antegrade or
retrograde .
 Antegrade nailing :- insertion of the nail through pyriform
fossa and transverse locking screws proximally and distally .
 Retrograde nailing :- insertion of the nail through
intercondylar notch at the knee . This operation control the
rotatory movement and ensures stability
External fixation

Main indication are :

1- Treatment of severe open injuries .
2- Patient with multiple injuries .
3- Severe bone loss which need to bone transport.
4- Femoral fracture in adolescence
 Advantage & disadvantage of intramedullary
nailing and external fixation
Advantage
 Not exposing the fracture site .
 Callus increase in the volume and quality .
 Promoting quicker consolidation by increase stress transfer to the fracture site
.
Disadvantage
 Pins-site infection .
 Most femoral shaft fracture will unite in under 5 month but some take longer if
the fracture is badly comminuted or contact between fracture end is poor
 Titanium Elastic Nail System(TENS)
 In recent times there has been an increasing trend towards
surgical intervention in pediatric femoral shaft fractures
with widening indications. Titanium elastic nails and
external fixation are two widely practiced procedures for
such fractures.
 TENS is preferred to internally fix the fracture in older
children(more than 10 years of age).
TIBIAL PLATEAU
FRACTURE
 The tibial plateau fracture occur in
proximal 10cm of tibia.
 These injuries can lead to significant
impairment of knee function due to
articular surface and involvement of the
collateral ligament.
 These are common fracture sustained in
two wheeler accidents when one lands on
knee.
 fractures of the tibial plateau are often
associated with injuries to the anterior
cruciate ligament, collateral ligaments
menisci and articular cartilage.
 MECHANISM OF INJURY
 tibial plateau fracture usually occur following a strong
varus or valgus combined with axial loading
 These fractures seen mostly road traffic accidents.
 fall from height,sporting activities and other common
mechanism.
 CLASSIFICATION
SCHATZER'S CLASSIFICATION:
 TYPE1: Pure cleavage # of the
lateral tibial plateau.
 Type 2: cleavage # + depression of
the lateral tibial plateau.
 Type 3: pure depression of the
lateral tibial plateau.
 Type 4: medial tibial plateau #
 Type 5: bicondylar #
 Type 6: extension of # line to
diaphysis.
 Diagnosis
 Pain and swelling around the knee are the common presenting
features.
 Edema, contusion, fracture blisters and compartment
syndrome signifies a severe injury to the soft tissues.
 Careful assessment of peripheral nerves and vessesls is
necessary.
 Standard radiographic views AP and LATERAL of the knee is
required.
 CT scan is often useful for further evaluation.
 TREATMENT
 NON-OPERATIVE METHODS:
• it is used in undisplaced or minimally displaced of the tibial plateau #
• simple immobilisation in a plaster,cast or knee brace.
• early knee mobilisation is encouraged to avoid knee stiffness
• weight bearing should be delayed until 6 weeks for sign of healing.
 OPERATIVE METHODS:
• most # with depression in the articular surface may be fixed with percutaneous
lag screws across condyles after the reduction of the # buttress plate may also be
required.
• if # involves both condyles, we can fix two buttress plates and cancellous screws.
• if the # is severely comminuted, it may be stabilized using a circular frame
 COMPLICATION
 associated soft tissue injury- rupture of collateral ligament
 vascular involvement- compartment syndrome and popliteal artery injury.
 post traumatic arthritis
 knee stiffness
 impaired fracture healing-malunion,non union
# to tibiaL shaft
Yuvraj Singh Gusain
 The tibia and fibula may be fractured by a
direct or indirect injury. MECHANISM
 Direct injury: Road traffic
direct violence.
Frequently the object causing the fracture
lacerates the skin over it, resulting in an open
fracture.

 Indirect injury: bending or torsional force on

the tibia may result in an oblique or spiral
fracture respectively.
CLINICAL FEATURES
• PAIN
• SWELLING
• DEFORMITY
• CREPITUS
• INABILITY TO USE LIMB ETC
• THERE MAY BE A WOUND
COMMUNICATING WITH THE
UNDERLYING BONE
Closed fractures: TREATMENT
 by closed reduction under anesthesia
followed by an above-knee plaster cast.

 In children, and the fracture unites -6 weeks.

In adults, the fracture unites 16-20 weeks.

 If reduction is not achieved, or the fracture

displaces in the plaster then ORIF.

 More and more unstable tibial fractures are

being treated with closed interlock nailing.
Open fractures:
 aim - open fractures is to convert it into a
closed fracture promote healing .
 depending upon the grade of open fracture:
 Grade I: Wound dressing through a
window in an above-knee plaster cast,
antibiotics.

 Grade II: Wound debridement and

primary closure ,above-knee plaster cast.
The wound may need dressings through a
window in the plaster cast.

 Grade III: Wound debridement, dressing

and external fixator application. The
wound is left open.
 Technique of closed
reduction
 Patient Under anesthesia The leg is kept
in traction using a halter, around the
ankle.

 The fracture ends are manipulated and

good alignment achieved.

 Initially, a below-knee cast is applied

over evenly applied cotton padding. Once
this part of the plaster sets, the cast is
extended to above the knee.
Wedging
• Sometimes, after a fracture has been reduced and the
plaster applied, check X-ray shows a little angulation
at the fracture site.

• In this technique, the plaster is cut circumferentially

at the level of the fracture, the angulation corrected
by forcing open the cut on the concave side of the
angulation, and the plaster reinforced with additional
plaster bandages.

• Once the fracture becomes 'sticky' (in about 6 weeks),

above-knee plaster is removed and below-knee PTB
(patellar tendon bearing) cast is put.
 Role of operative treatment
 ORIF is necessary when it is not possible
to achieve a satisfactory alignment of a
fracture by non-operative methods.

 internal fixation device -plate or an intra-

medullary nail depending upon the
configuration of the fracture.

 Interlock nailing provides the possibility

of internally fixing a wide spectrum of
tibial shaft fractures.
Deciding
the plan
for
treatment
 Complication
related to tibial
fracture
M.ATIF
 COMPLICATION
Malunion
Compartment syndrome
Infection
 Delayed union and non-union
Malunion

Some amount of angulation is acceptable in children as it gets

corrected by remodelling. In adults, displacements especially
angulations and rotations are not acceptable. These cause
problems in walking and result in early osteoarthritis of the
knee and ankle.
 Treatment requires correction of the deformity by redoing
the fracture and fixing it by plating or nailing, and bone
grafting.
Compartment syndrome

Some cases of closed fracture of the tibia may be

associated with significant crushing of soft
tissues, leading to compartment syndrome.
A compartment syndrome should be suspected
if a fracture of the tibia is associated with
excessive pain, swelling and inability to move
the toes. Immediate operative decompression of
the compartments is imperative.
Infection

Most often the infection is superficial and is

controlled by dressing and antibiotics. Sometimes,
the underlying bone gets infected, in which case more
elaborate treatment on the lines of osteomyelitis may
be necessary . The fracture in such cases often does
not unite. Ilizarov's method is the treatment of choice
in such infected non-unions
Delayed union and non-union

The most important factor responsible for delayed and non-union

is the precarious blood supply of the tibia; others being frequent
compounding with loss of fracture haematoma, wound infection,
etc.

Treatment: Treatment of delayed union and nonunion is essentially

by bone grafting, with or without internal fixation. Following
treatment options are available:
 a) Nailing with bone grafting: This is
indicated in cases of non-union, where the
alignment is not acceptable, or there is free
mobility at the fracture site. Some surgeons
prefer plating and bone grafting.
b) Phemister grafting: This is a type of
bone rafting done for selected cases which
fulfil the following criteria:
 There is minimal or no mobility at the
fracture site (fibrous union).
 The fracture has an acceptable alignment.
 The knee joint has a good range of
movement. In this technique, grafting is
performed without disturbing the sound
fibrous union at the fracture site. The aim is
to stimulate bone formation in the ‘fibro-
cartilaginous tissue’ already bridging the
fracture. Cancellous bone grafts are placed
after raising the osteoperiosteal flaps
around the fracture
c) Ilizarov's method: This method is useful in
treatment of difficult non-unions of tibia. These
are non-unions with bone gap, infection, or
those with bad overlying skin.