Fractures of the Femur, Tibia, and Fibula Presented by: Dr. Aric Storck October 2, 2002

Objectives 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 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 No generally accepted system Describe based on characteristics Location Geometry Transverse, oblique, spiral, wedge, comminution

Femoral Shaft Fractures Transverse closed femur fracture at junction of proximal and middle thirds

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

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

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

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

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

Ottawa Knee Rules 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 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 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 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 If Ottawa criteria are met x-ray: AP / Lateral “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 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 Uncommon Result from high velocity trauma (MVC) Hyperabduction Adduction Hyperextension Axial loading Extensive soft tissue injuries Compartment syndrome - rare

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

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

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

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

Distal Femur Fractures

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

Distal Femur Fractures Complications – similar to femoral shaft dvt 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 Management assess & manage neurovascular status analgesia (consider femoral nerve block) immobilization appropriate fluid management orthopedic referral definitive treatment (ORIF vs conservative)

Distal Femur Fractures Closed supracondylar fracture following MVC

Distal Femur Fractures One year post ORIF

Distal Femur Fractures Transcondylar fracture post mvc

Distal Femur Fractures Transcondylar fracture 10 months post ORIF

Distal Femur Fractures Femoral shaft and intercondylar fracture. Before and after

Patellar Fractures 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 Knee/acetabular dislocations Acetabular fractures Femur fractures

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

Patellar fractures

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

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

Transverse Patellar Fracture

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

Patellar Fractures ++articular damage 58 year old dashboard injury and comminution of patella

Patellar Fractures After total patellectomy and repair of the extensor mechanism

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

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

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

Tibial Plateau Fractures Imaging if meets Ottawa rules 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)

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 4. Medial plateau fracture (15%)

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

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

Tibial Plateau Fracture. Type? Schatzker 1 with comorbid fracture of medial femoral condyle

Tibial Plateau Fracture. Type?

Tibial Plateau Fracture - Type?

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

Tibial Plateau Fractures Complications 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 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 Type I Type II Type III Incomplete avulsion with no displacement Type II incomplete avulsion with displacement Type III Completely avulsed fragment

Tibial Spine Injury Type II tibial spine avulsion fracture

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

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

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

Tibial tuberosity fractures Type II tibial tuberosity fracture

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

Tibial Shaft Fracture 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 No universally accepted classification scheme. Describe the following Location (prox, middle, distal third) 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 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 Orthopedic referral No consensus exists re: definitive treatment Multifactorial decision Possible management ORIF Intramedullary rod Cast immobilization Early progressive weight bearing after two weeks

Tib/Fib Fractures 1. Moderately comminuted fracture. 2. 3months after fixed with plate and screws. Note that fibula not repaired

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

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

Fibular Shaft fractures Treatment 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