Common lower limb fracture Dr Tarif Alakhras Orthopedic surgeon kfmc

Common lower limb fracture Fracture of the proximal femur (hip fracture) Fracture of the shaft of the femur Fracture of the distal femur Fracture of the proximal tibia Fracture the shaft of the tibia Ankle fractures

Blood Supply to Femoral Head Artery of Ligamentum Teres Most important in children. Its contribution decreases with age, and is probably insignificant in elderly patients. Ascending Cervical Branches. formed by branches of medial and lateral circumflex femoral arteries. Penetrate capsule near its femoral attachment and Highly susceptible to injury with hip dislocation.

Hip fracture Intracapsular v extracapsular The capsule envelopes the femoral head and neck Intertrochanteric and subtrochanteric fractures do not involve the neck of femur

Hip fracture Capsule Area Intracapsular femoral head femoral neck Subcabital Transcervical Basicervical Extracapsular Intrtrochanteric subtrochanteric

Femoral Head Fractures A rare fracture pattern. requires high amounts of energy. The classic mechanism of injury for femoral head fracture is traumatic posterior dislocation of the hip

Femoral Head Fractures Examination of the injured hip often reveal hip pain & shortened lower extremity  neurologic examination is important to rule out sciatic nerve injury an ipsilateral knee examination is also required with attention paid to ligamentous stability (dashboard injury)

Femoral Head Fractures  The CT scan is not only important for assessing the femoral head fracture pattern (size, location, comminution), but also to evaluate the congruity of the hip joint and determine the presence or absence of intra-articular loose fragments.

Femoral Head Fractures Treatment Fracture-dislocation of the hip is a true orthopaedic emergency. The goals of definitive treatment of femoral head fractures are to achieve an anatomic reduction, achieve and maintain joint stability, and remove any interposed bone fragments. decision-making process.

Femoral Head Fractures Nonoperative treatment closed reduction and skeletal traction  if close reduction is possible and the hip joint is stable for fracture with less than 1 mm of displacement on CT scan.  Operative treatment The indications for surgical management include nonanatomic reduction of the femoral head articular surface, an unstable hip joint, and the presence of intra-articular incarcerated fragments that are preventing a congruent joint reduction

Femoral Neck Fractures These injuries occur in 2 distinct populations, (1) young, active individuals (2) elderly individuals with osteoporosis It is more common in the elderly and female. Whites > blacks

Femoral Neck Fractures Mechanism of injury: Elderly osteoporotic people :simple fall, with twisting the hip into external rotation. young, active individuals: usually caused by a high-energy impact (fall from height or RTA). Stress fracture of the femoral neck occur in runner or military personnel.

Femoral Neck Fractures Presentation Hip pain may radiate to the knee. inability to bear weight. The affected leg may be shortened, adducted and externally rotated. Pain over the hip may be particularly aggravated by rotation of the leg.

Femoral Neck Fractures Garden classification - Simulation I - Incomplete or impacted bone injury II - Complete (across whole neck) - undisplaced III - Complete - partially displaced IV - Complete - totally displaced

Femoral Neck Fractures Surgery should be performed on the day of, or the day after, admission. Internal fixation with screws if undisplaced  displaced intracapsular fractures may be treated either by reduction and internal fixation in younger fit patient<50 years, or by replacement of the femoral head in older less fit patients. Internal fixation is associated with less initial operative trauma but has an increased risk of reoperation on the hip.

Femoral Neck Fractures

Femoral Neck Fractures Complications Nonunion 5% of non-displaced 25% of displaced fractures Osteonecrosis 0% of non-displaced 27% of displaced fractures

Intertrochanteric fractures trochanteric hip fracture occurs between the greater trochanter, where the gluteus medius and the gluteus minimus (hip abductors) attach, and the lesser trochanter, where the iliopsoas (hip flexor) attaches

Intertrochanteric fractures Frequency Among individuals older than 60 years, intertrochanteric fractures occur more than twice as often in women as in men. elderly, osteoporotic women In the age group between 11 and 60 years, however, males sustain more fractures than females. Due to high-energy trauma

Intertrochanteric fractures Etiology Increased bone fragility of the intertroch area from osteoporosis and osteomalacia secondary to a lack of adequate ambulation or antigravity activities, as well as decreased hormone levels, decreased intake of calcium or vitamin D, and other aging processes. Benign and malignant tumors, along with metastases such as multiple myeloma and other malignancies, can also lead to weakened bony structure.

Intertrochanteric fractures Clinical evaluation Inability to bear-weight Limb is short, abducted and externally rotated Radiological evaluation AP ,Lateral ,pelvic ,chest Joint above and joint below should be included

Intertrochanteric fractures Coexisting or preexisting conditions Pulmonary insufficiency Cardiac insufficiency Cardiovascular insufficiency Hypertension Dehydration & Malnutrition metabolic diseases or endocrine diseases, (diabetes and hypothyroidism) A younger patient with a high-energy fracture has the potential for multiple other injuries to the remainder of the body, especially the head, chest and abdomen.

Intertrochanteric fractures Current treatment of intertrochanteric fractures is surgical intervention.  Proximal femoral nail Dynamic hip screw (DHS)

Intertrochanteric fractures nonsurgical management accompanied by unacceptable morbidity and mortality because of frequent complications associated with prolonged immobilization or inactivity. Such complications included the following: Pulmonary embolism (PE) from deep vein thrombosis(DVT) Pressure ulcers  Joints stiffness and muscle atrophy Malunion, the fracture heals with unacceptable shortening, rotation, or angulation of the extremity

Femoral shaft fractures High mechanism of energy Inability to bear weight AP & lateral radiographs Two joints veiw Bleeding: Can easily loose 2L of blood Risk of thromboembolism

Femoral shaft fractures Treatment : always surgical intramedullary nail is the best. Platting is another option

Distal Femur Fractures Defined as fxs from articular surface to 5cm above metaphyseal flare Supracondylar or intercondylar Mechanism young patients high energy with significant displacement older patients low energy in osteoporotic bone with less displacement

Distal Femur Fractures potential for injury to popliteal artery if significant displacement if no pulse after gross alignment restored then angiography is indicated

Distal Femur Fractures Radiographs obtain standard AP and Lat AP, Lat CT obtain with frontal and sagittal reconstructions useful for establish intra-articular involvement identify separate osteochondral fragments in the area of the intercondylar notch preoperative planning Angiography indicated when diminished distal pulses after gross alignment restored

Distal Femur Fractures Treatment Nonoperative knee brace with NWB for 6 weeks indications (rare) nondisplaced fractures nonambulatory patient patient with significant comorbidities Operative open reduction internal fixation indications displaced fracture intra-articular fracture nonunion

Tibia and Fibula Fracture Mechanism of injury Direct forces such as those caused by falls and MVCs( transverse frx) More soft tissues injury Indirect or rotational forces (spiral frx) less injury to the soft tissues

Most common open fracture Most common long bone fracture Most common open fracture Bone immediately under skin Significant cost 569,000 hospital days (USA) Significant complications Nonunions , compartment syndrome

Tibial shaft fracture : treatment Conservative Shortening <1cm Angulation in varus/valgus plane< 5o Angulation in antero-posterior plane <10o Rotation neutral to slight external rotation Bone apposition >50%

Tibial shaft fracture : treatment Long leg cast (5 degrees of flexion) for 4-6 weeks patella-bearing cast(Sarmiento) or fracture brace The average union time is 16±4 weeks

Tibial shaft fracture : treatment Surgical treatment Intramedullary (IM) Nailing is the best treatment for mid shaft tibia fracture The most complication is anterior knee pain!!

Surgical treatment Plate fixation 97% success rates Complication: i infection, wound breakdown, nonunion i

Tibial plateau fractures Occur from axial loading with valgus or varus forces, such as in a fall from a height. The lateral tibial plateau is fractured more frequently than the medial plateau. Presented by knee effusion lead to early OA in the knee joint. Treated conservatively or surgically depending on the degree of displacement & joint surface disruption.

Ankle fracture Together, the distal tibia and fibula form a concave mortis in which the talus is firmly held by the medial (deltoid) and lateral collateral lig.

Ankle fracture Neer pointed out that the tibia, fibula, talus and connecting ligaments form a closed circle similar to the pelvic. Interruption at one side is usually associated with remote injury

Ankle fracture Most ankle fractures are isolated malleolar fractures. Medial malleolus Lateral malleolus Posterior malleolus   Mechanism of injury: position of the foot at time of injury, the magnitude, direction, and rate of loading

Ankle fracture Evaluation - Common symptoms for a broken ankle include: Immediate and severe pain Swelling & Bruising Tender to touch Cannot put any weight on the injured foot Deformity

Ankle fracture Radiographic Foot in 15o of internal rotation AP & Lateral Mortise views Foot in 15o of internal rotation

Ankle fracture

Ankle fracture Denis –Weber classification Based on fibular fracture: A. Infra-syndesmotic B. Trans-syndesmotic C. Supra-syndesmotic: usually syndesmosis is torn

Ankle fracture Denis –Weber classification Bimalleolar feactur

 Maisonneuve fracture.

Ankle fracture Undisplaced: Indications for ORIF Below knee cast (NWB) All fracture-dislocations All type C fractures Tri-malleolar fractures Talar shift or tilt Failure to achieve or/maintain closed reduction

Ankle fracture Syndesmotic injury With out syndesmotic injury