Curs 5 - Engl + Astragal

Fractures of the lower limb
Prof. Univ. Dr. Grecu Dan

I. Fractures of the femoral head
• Generally rare, due to the local mechanical protection of the femoral
head
• Associated with luxation of the femoral head
• I.1. Incidence
Young males, high physical activity
• I.2. Classification: Pipkin Classification follows the fracture trajectory
through the femoral head
• Type 1: Antero-inferior, 10-15mm, osteo-condral shell aspect
• Type 2: Voluminous fracture, up to 1/3 of the diameter of the femoral head,
with the round ligament remaining attached to the distal fragment
• Type 3: Type 1 or Type 2 fracture associated with a fracture of the femoral
neck
• Type 4: Type 1 or Type 2 fracture associated with a fracture of the acetabular
lip
• I.3. Mechanism of occurrence
High impact trauma: car accidents, sport accidents
Hip in forced flexion – adduction – internal rotation, same as pure hip luxation
• I.4. Clinical exam
• Inspection: position characteristic for a posterior hip luxation – flexion,
adduction and internal rotation of the hip
• After repositioning of the hip -> persistent pain upon palpation of the base of
the femoral trigon and the great trochanter
• Total functional impotence of the hip
• I.5. Radiological examination
Rx + CT scan -> Usually states the diagnosis
The fracture usually has a horizontal trajectory
Type 2 Pipkin fracture;

Rx and CT scan
• I.6. Treatment = surgical treatment
• Depending on the type, associated lesions and age of the fracture:
• Excision of the loose osteo-chondral fragment
• Surgical reduction and osteosynthesis
• Bipolar or total hip arthroplasty
• Hip arthrodesis in the case young, hard work patients that refuse to change
their work
• I.7. Prognosis
• Intra-articular position Late and frequent:
• Vascular complications - Arthrosis
- Avascular necrosis of the
femoral head
II. Fracture of the femoral neck
• Bad callus formation
• Short and medium term general complications due to prolonged
decubitus
• Local long term complications
• II.1. Classification
• Delbet classification: location of the fracture
• Subcapital fractures
• Medio-cervical fractures
• Base of the femoral neck fractures
• Powels classification: angle of the fracture trajectory and the
horizontal
• Powels Type 1: angle < 30
• Powels Type 2: angle = 30-50
• Powels Type 3: angle > 50
• Söeur classification: after where the Adams hook remains attached
• Fracture with proximal hook: corresponds to Powels Type 1 fracture, better
prognosis
• Fracture with distal hook: corresponds to Powels Type 3 fracture, worse
prognosis
• Garden classification: most commonly used
• Garden Type 1: incomplete fracture, without reaching the inferior cortical
• Garden Type 2: complete fracture, without fragment moving
• Garden Type 3: complete fracture, with slight fragment malposition. Small
rotation of the inferior limb. Blood vessels still intact. Fracture site opens like
a book.
• Garden Type 4: complete fracture with big fragment moving.
• Garden classification: most commonly used
• Garden Type 1: incomplete fracture, without reaching the inferior cortical
• Garden Type 2: complete fracture, without fragment moving
• Garden Type 3: complete fracture, with slight fragment malposition. Small
rotation of the inferior limb. Blood vessels still intact. Fracture site opens like
a book.
• Garden Type 4: complete fracture with big fragment moving.
Garden Type 1 fracture




• Cooper classification:
• Intra-capsular fractures: the most common
• Extra-capsular fractures
• II.2. Incidence
• Especially elderly patients, with osteoporosis, mostly women,
especially in the winter
• II.2. Incidence
• Especially elderly patients, with osteoporosis, mostly women,
especially in the winter
• II.3. Mechanism of occurrence

• Accidental fall on the hip, usually on ice, usually with the femur in
external rotation
• II.4. Clinical examination
• Spontaneous and palpation pain
• Total functional impotence
• External rotation of the affected limb. “Cadaver position” of the
affected limb. Present in fractures with fragment malposition.
• Shortening of the affected limb. Present in fractures with fragment
malposition
• II.4. Clinical examination
• Laugier sign: deformation of the base of the femoral triangle. Visible
on skinny patients
• Adduction of the affected limb
• Addis sign:
• Hypotrophy of the middle gluteus and the fascia lata
• The level of ascent of the great trochanter:
• Bryant triangle deformed
• Schömaker line malposition
• Peter line malposition
• II.5. Radiological investigation
• Anterior-posterior incidence, sets the diagnosis
• II.6. Treatment
• Orthopedic treatment -> only due to fear of complications
• Surgical treatment -> first choice:
• Orthopedic reduction and osteosynthesis under RxTV
• Medialization/valgization osteotomy
• Hip arthroplasty
• Hip arthrodesis
• II.6. Treatment
• Garden Type 1 and Garden Type 2 fractures -> osteosynthesis
• Garden Type 3 -> osteosynthesis depending on the age of the fracture
• In some cases, where the surgical risk is too big, or the patient refuses
surgery, the doctor conducts the patient to a pseudarthrosis: 14 days
of anti-rotatory cuff followed by walking
• II.6. Treatment
Osteosynthesis with 2 parallel
screws for Garden Type 2
fracture
• II.6. Treatment
• Partial hip
Total hip
arthroplasty
arthroplasty
• II.7. Complications
• Immediate due to prolonged decubitus:
• Local late complications: pseudarthrosis, avascular necrosis of the
femoral head. The greater the age of the patient, the greater the risk
of complications
Avascular necrosis after

osteosynthesis for a fracture of the
femoral neck
• Immediate due to prolonged decubitus:
• Local late complications: pseudarthrosis, avascular necrosis of the
femoral head. The greater the age of the patient, the greater the risk
of complications
III. Trochanteric fractures
• From the base of the femoral neck to the inferior limit of the lesser
trochanter
• Numerous muscle insertions -> pseudarthrosis = rare
III.1. Mechanism of occurrence
Fall from the same level -> usual
Ripping of the greater trochanter by the lesser and middle gluteus
muscle -> rare
III.2. Classification: Decoulx and Lavarde
• Cervical-trochanteric fractures: fracture spans from the neck of the
femur to the trochanteric region
• Simple Pertrochanteric fracture: oblique descending trajectory, from
the external to the internal, from the tip of the greater trochanter
to/under the lesser trochanter
• Complex Pertrochanteric fracture: same as simple fracture, but with
great comminution, destruction of the posterior wall and detaching of
the lesser trochanter
Complex Pertrochanteric fracture
III.2. Classification: Decoulx and Lavarde
• Intertrochanteric fractures: horizontal trajectory, from the greater
trochanter to the superior limit of the greater trochanter
III.3. Clinical examination
• Vivid pain of the affected hip, greater in the projection area of the
trochanteric region
• Shortening of the affected limb (5-7 cm) in fractures with fragment
moving
• “Cadaver position” of the affected limb: external rotation, in fractures
with fragment moving
• Adduction
III.3. Clinical examination
• Increase of the transverse diameter of the base of the thigh due to
the external rotation and the primary fracture hematoma
• Late ecchymosis present on the internal and external faces of the
proximal 1/3 of the thigh. Differential diagnosis with fractures of the
head of the femur.
• Allis 2 clinical sign: the greater trochanter “rolls” in the palm on
external and internal mobilization
III. 4. Prognosis
• Pseudarthrosis = rare
• Complications generally due to age of patient
III.5. Treatment
• Surgical treatment = closed reduction and osteosynthesis = treatment
of choice
• Orthopedic treatment = only in cases of absolute contraindications
Dynamic Hip Screw Elastic
(DHS) Ender type
rods
III.6. Complications
General:
• Decubitus eschar: can be prevented only with moving of the patient
from side to side
• Pulmonary congestion, pulmonary abscess, pneumonia: leads to lack
of function of the lung, is caused by prolonged decubitus, can be
prevented by early mobilization
• Thrombophlebitis: serious complication, can be prevented with
anticoagulants
Local:
• Vicious callous: is the rule without surgical treatment and can happen
even with proper surgery
• Knee pain: usually in the case of elastic rods, difficult to rehabilitate
Local:
• Vicious callous: is the rule without surgical treatment and can happen
even with proper surgery
• Knee pain: usually in the case of elastic rods, difficult to rehabilitate
IV. Sub-Trochanteric fractures
The fracture trajectory spans from the inferior edge of the lesser
trochanter to 5 cm distal to it
IV.1. Mechanism of occurrence
Direct fall or torsion with the foot planted on the fixed basis
IV.2. Classification
Regarding the localization:
• Sub trochanteric fractures
• Trochanter – sub trochanter fractures
• Trochanter – diaphysis fractures
IV.2. Classification
Regarding the fracture trajectory:
• Fractures by abduction: from the proximal to the distal and from
external to internal
• Fractures by adduction: from the proximal to the distal and from
internal to external
• Comminuted fractures
IV.3. Clinical examination
• Vivid pain at the base of the thigh
• External rotation of the affected limb
• Shortening of the affected limb
• Late ecchymosis at the base of the thigh
• Deformation of the region with increase of the transverse diameter
• Palpation -> interruption of bone continuity
IV.4. Radiological examination
Usually anterior-posterior view sets the diagnosis
IV.5. Treatment
Surgery -> election treatment, orthopedic or surgical reduction +
osteosynthesis
Sub trochanteric fracture

operated with 3 elastic
Ender type rods
Comminuted sub
trochanteric fracture
operated with long
gamma nail
IV.6. Complications and prognosis
Same as other hip fractures + the risk of an open fracture due to sharp
fracture fragment -> penetration of the skin
V. Fracture of the diaphysis of the femur
From 3 cm distal to the inferior edge of the lesser trochanter to ~ 10 cm
proximal of the femoral condyles.
V.1. Mechanism of occurrence
Direct or indirect
Fractures of the distal 1/3 of the diaphysis: direct impact mechanism
V.2. Classification
• Transverse
• Long or short oblique
• Comminuted
• Bi-focal fracture
V.3. Clinical examination
• Patient can be in shock due to the high impact trauma or to the blood
loss from the fracture (can be 1000 ml blood)
• Pain: constant, intense, accentuated by palpation, calmed by
immobilization
• Thigh deformation
• Abnormal mobility, untransmisibility of motion
• Bone cracments
V.3. Radiological examination
Anterior—posterior view is usually enough
V.4. Treatment
Surgery = election treatment
Osteosynthesis with Kűntscher Rigid fixation nail, etc.
Fracture of the upper 1/3,
osteosynthesis with rigid nail and
dynamic screw
Fracture of the proximal 1/3
operated on with Centro
medullar nail
VI. Supracondylar femoral fracture
The distal fragment is pulled by the gastrocnemius muscles inserted on
it and Is rotated posteriorly while the proximal fragment pushes against
the subquadricipital cul-de-sac and penetrates the knee
VI.1. Clinical diagnosis
• Pain, accentuated by movement and palpation
• Abnormal mobility
• Bone cracments
• Palpable bone interruption
• Anterior-posterior diameter increase
• Late ecchymosis
• Possible hemartrosis
VI.2. Radiological diagnosis
Anterior posterior and lateral view enough to establish diagnosis
VI.3. Treatment
Orthopedic treatment possible only in cases of fracture without
fragment moving. Immobilization or continuous extension.
Surgical treatment: most used = osteosynthesis with DCS (Dynamic
Condylar Screw), plates and screws
DCS
VI.4. Complications
Vascular and nervous complications due to possible injury of the
popliteus region
VII. Fracture of the Patella
VII.1. Mechanism of occurrence
Direct fall with support on the knee, household accidents, auto, sports,
etc.
VII.2. Clinical diagnosis
• Pain at fracture site
• Functional impotence -> impossible to actively extend the knee.
Flexion possible normally.
• Late ecchymosis that tends to spread distally + tumefaction
• “pencil sign” the two fragments are so distant that you can introduce
a pencil/finger between them
• !! No bone crepitation, because the bone fragments are not in
contact!!
VII.3. Radiological exam
Anterior-posterior and lateral
views set the diagnosis
VII.4. Treatment
In cases where the fragments do not move (incomplete fracture) ->
orthopedic treatment, femuro-tibial immobilization for 6 weeks
Surgical treatment:
• "figure-of-eight" configuration tension band. The figure-of-eight band
presses the two pieces together.
• Circle performed around the patella with wire, through the patellar
ligament and the tricipital tendon
"figure-of-eight"
configuration
tension band
Double cerclage with wire

VII.5. Functional rehabilitation
The main concern in knee stiffness -> as early mobilization as possible
VII.6. Complications
• Limitation of flexion: 23-30 degrees of flexion lost, but with good life
quality
• Femuro-patellar arthrosis: it is the rule, because the cartilage does
not recuperate
VII. Fracture of the Tibial Plateau
Clasification:
AO simplified:
Clasification by Schatzker:
Clasification by Schatzker:
Clinical signs:
–Pain.
–Hemartrosis.
–Abnormal mobility.
–Functional disability.
Rx:
Treatment:
–Orthopedic: rare case. Is leading to stiff knee.
Surgical:
–Most of the cases.
–Close reduction and screws: possible for Schatzker I, II, III, maybe IV, V
–ORIF with plate and screws (angular stability): for Schatzker IV, V, VI.
VIII. Fracture of the diaphysis of the tibia
VIII.1. Mechanism of occurrence
Indirect trauma -> most often
Direct trauma -> more often than other locations and cause open
fractures
VIII.2. Clinical diagnosis
• Pain, deformation, edema
• Blisters due to high internal pressure
• Ecchymosis
• Interruption of bone continuity, abnormal bone motions
• Bone crepitation
• Untransmisibility of motion in case of both the tibia and the peroneus
fracture
VIII.3. Radiological examination
Anterior posterior and lateral views set the diagnosis
VIII.3. Classification
Regarding the localization:
• In the upper third of the diaphysis -> can interest the nutritive artery
of the tibia that leads to important hematoma -> compartment
syndrome -> possible amputation, delay in bone consolidation
• In the middle third of the diaphysis -> most rarely associated with
peroneus fractures
• Distal third of the diaphysis of the tibia -> most often associated with
peroneus fractures
VIII.3. Classification
Regarding the fracture trajectory:
• Transverse fractures: peroneus intact and no signs of shortening
• Oblique short or long fractures ± peroneus fracture
• Spiroid fractures: almost always interest the peroneus in its upper
third
• Comminuted fractures: generally interest both bones, with associated
skin lesions
• Double fracture of the tibia: tibia bone fractured in two different
places. Do not confuse with both bones fracture!
Oblique distal fracture in
the distal 1/3
Spiroid fracture of the
tibia
Comminuted, proximal
1/3 tibia fracture
Double fracture of the
tibia
Medium 1/3 fracture of
both bones with
intermediary fragment
VIII.4. Treatment
Immobilization: Stable, without movement fractures
Surgical treatment: unstable fractures; reduction and osteosynthesis
Open fractures are fixed using an external fixation.
Sometimes, due to skin defects, the help of the Plastic Surgery
department is necessary
VIII.5. Complications
• Open fractures
• Anterior or posterior compartment syndrome -> emergency
treatment
• Posttraumatic thrombophlebitis
• Fatty emboli difficult to prevent and treat
• Post thrombotic syndrome and chronic edema -> difficult to treat.
Physiotherapy
• Delay in consolidation
VIII.5. Complications
• Open fractures
• Anterior or posterior compartment syndrome -> emergency
treatment
• Posttraumatic thrombophlebitis
• Fatty emboli difficult to prevent and treat
• Post thrombotic syndrome and chronic edema -> difficult to treat.
Physiotherapy
• Delay in consolidation
IX. Fracture of the ankle
The ankle articulation consists of three bones: tibia, peroneus and
astragal that allow for flexion-extension motion
IX.1. Mechanism of occurrence
Indirect -> most often.
Inversion = adduction – internal rotation – supination
Eversion = abduction – external rotation - pronation
Direct -> associated with open fractures
IX.2. Classification
Anatomical:
• Single malleolus fractures: internal or external
• Bi malleolus fractures: internal and external
• Low bi malleolus fractures
• Dupuytren type fracture: internal and external malleolus fracture 10 cm away
from the articular line
• High Dupuytren (or Maissoneuve) type fracture: internal malleolus fracture
associated with proximal third peroneus fracture
Anatomical:
• Complex: fractures that affect other anatomical elements
concomitantly
• Bi malleolus + posterior edge of the tibia (incorrectly called tri malleolus
fractures)
• Bi malleolus + anterior edge of the tibia
• Associated with the tibia pylon
Anatomical:
• Equivalent fractures: fractures of one malleolus + ligament rupture in
the area of the opposing malleolus. Most often external malleolus
fracture + rupture of the deltoid ligament
Weber-Denis classification: fracture of the external malleolus in
relation to anterior and posterior tibia-peroneal ligaments
• Subligamentary fracture
• Intraligamentary fracture: pseudodiasthasis of the tibia and peroneus
• Supraligamentary fracture: true diasthasis of the tibia and peroneus
IX.2. Clinical diagnosis
• Pain, transverse and anterior-posterior increase in diameter deformation
• Deformation of the ankle axis: Valgus or Varus
• Ecchymosis that spreads to the toes
• Edema, Phlyctène
• Abnormal bone mobility
• Interruption of bone continuity: most often palpable at the internal
malleolus
• Crepitation absent at the internal malleolus because the fragments are not
in contact
IX.3. Radiological diagnosis
Anterior-posterior and lateral view set the diagnosis
IX.4. Treatment
Orthopedic treatment: first choice in cases without movement of the
fragments. Orthopedic reduction + immobilization.
Surgical treatment:
• In cases of orthopedic treatment failure
• Big fragment movement
• Soft tissue interposition
• Unstable fractures
IX.4. Treatment
• Surgical treatment must be extremely precise
• In cases where the surgeon has to choose, an imperfect orthopedic
treatment is preferred to an imperfect surgical treatment
“tri malleolus” fracture

+ postero-external
subluxation
Comminuted tibia pylon + peroneus malleolus

Screws osteosynthesis on the tibia pylon + plate and screws
on the peroneus malleolus
IX.5. Prognosis
Generally good if reduction is good
Can lead to chronic edema and arthrosis
IX.5. Complications
• Ankle stiffness
• Edema of the ankle due to capillary circulation injury
• Algic osteoporosis
• Pseudarthrosis
• Vicious callous
• Ankle arthrosis
Ankle arthrosis
secondary a “tri
malleolus” fracture
X. Fractures of the astragalus
Complex, hard bone with no muscular insertion -> bad vascularization.
-> fractures are rare, and with bad consolidation
X.1. Mechanism of occurance
Indirect -> most often
Direct -> rare: gunshot
X.2. Classification
Anatomo-clinical:
• Fracture of the neck of the astragalus
• Fracture of the body of the astragalus
• Fracture of the posterior aphophysis of the astragalus
X.2. Classification
Classification of the fractures of the neck of the astragalus:
• Type 1: Fractures with no or minimal movement. Necrosis still
possible
• Type 2: Fractures with big movement, subluxation of the astragalus
body, they compromise 2/3 of vascularization. Necrosis highly likely.
• Type 3: Fractures with full luxation of the astragalus body. They
compromise the entire circulation. Necrosis certain.
X.3. Clinical diagnosis:
• Pain and functional impotence
• Ankle deformation; enlarged transverse diameter
• Varus equine position in cases of Type 2 astragalus neck fractures
• Hurtful, globe-like tumefaction of the tibia pylon, anterior of the
Achilles tendon, which is the luxated astragalus body in Type 3 neck
fractures of the astragalus
X.4. Radiological diagnosis
Anterior-posterior and lateral view set the diagnosis
X.5. Treatment
Orthopedic treatment: in cases of fracture without movement,
immobilization for 8-9 weeks
Surgical treatment: laborious and very precise, it must not hurt the
vascularization even more. In Type 2 and Type 3 fractures.
-> surgical reduction + osteosynthesis by broche or screws followed by
immobilization
X.6. Prognosis -> generally reserved
Type 1 fractures tend to consolidate well
Type 2 and Type 3 fractures often lead to pseudarthrosis and avascular
necrosis of the astragalus body, with important functional deficit.
XI. Fracture of the calcaneus
Spongious, complex shape, good vascularization bone.
XI.1. Mechanism of occurrence
Indirect mechanism: fall on the foot or explosion under the foot/
ripping caused by the sudden contraction of the sural triceps muscle
XI.2. Classification: simplified Burghele
• With thalamic interest:
• Without fragment movement
• With horizontal immersion
• With vertical immersion
• With mixed immersion
• Comminuted fractures
XI.2. Classification: simplified Burghele
• Extra thalamic fractures
• Fractures of the great tuberosity: horizontal, parrot beak
• Fracture of the great apophysis
• Fracture of the sustentaculum tali
• Complex fractures: associated fractures present
XI.2. Classification: Böhler (reference point = Böhler angle = the straight
line that unites the superior pole of the thalamus and the beak of the
great apophysis angled with the tangent of the superior edge of the
great tuberosity)
XI.2. Classification: Böhler
Böhler type 1: angle over 20 degrees
Böhler type 2: angle ~ 0 degrees
Böhler type 3: angle under 0 degrees
XI.3. Clinical diagnosis
• Constant pain
• Late ecchymosis at plantar level
• Local deformation
• Functional impotence
XI.4. Radiological diagnosis
Lateral and axial view of the calcaneus set the diagnosis and establish
the Böhler classification
XI.5. Treatment
Orthopedic treatment in cases without fragment movement.
Immobilization followed by no load bearing on the affected member
Surgical treatment:
Microsurgery by two broches in Böhler type 2 fractures
Surgery with rising of the articular surface and filling the gap with bone
material + osteosynthesis with plates and screws in Böhler type 3
fractures
XI.6. Prognosis
There fractures always consolidate.
Often they cause vicious callous, algic osteoporosis, under-astragalin
arthrosis
Thank You!!

Curs 5 - Engl + Astragal

Hochgeladen von

Dokumentinformationen

Originaltitel

Copyright

Verfügbare Formate

Dieses Dokument teilen

Dokument teilen oder einbetten

Freigabeoptionen

Stufen Sie dieses Dokument als nützlich ein?

Sind diese Inhalte unangemessen?

Copyright:

Verfügbare Formate

Curs 5 - Engl + Astragal

Hochgeladen von

Copyright:

Verfügbare Formate

Fractures of the lower limb

Prof. Univ. Dr. Grecu Dan

Type 2 Pipkin fracture;

Garden Type 1 fracture

Garden Type 2 fracture

Garden Type 3 fracture

Garden Type 4 fracture

• II.3. Mechanism of occurrence

Avascular necrosis after

Sub trochanteric fracture

Double cerclage with wire

“tri malleolus” fracture

Comminuted tibia pylon + peroneus malleolus

Das könnte Ihnen auch gefallen