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

2. 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

3. Femur Fractures

4. 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

5. Femoral Shaft Fracture Classification
No generally accepted system
Describe based on characteristics
Location
Geometry
Transverse, oblique, spiral, wedge, comminution

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

7. 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

8. 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)

9. 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

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

11. 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 litres)
Concurrent multisystem trauma
Limb-length discrepancy
Compartment syndrome of the thigh - rare

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

13. 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

14. 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

15. 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: , 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: , 1997

16. 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

17. Pittsburgh Rules for Knee Radiographs

18. 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

19. 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

20. Distal Femoral Fractures

21. Distal femur fractures
Uncommon
Result from high velocity trauma (MVC)
Hyperabduction
Adduction
Hyperextension
Axial loading
Extensive soft tissue injuries
Compartment syndrome - rare

22. 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

23. Femur fractures - imagingAP
Lateral
Also don’t forget …
AP pelvis
AP/lateral hip

24. 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

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

26. Distal Femur Fractures

27. 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

28. 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!!)

29. Distal Femur Fractures
Management
assess & manage neurovascular status
analgesia (consider femoral nerve block)
immobilization
appropriate fluid management
orthopedic referral
definitive treatment (ORIF vs conservative)

30. Distal Femur Fractures
Closed supracondylar fracture following MVC

31. Distal Femur Fractures
One year post ORIF

32. Distal Femur Fractures
Transcondylar fracture post mvc

33. Distal Femur Fractures
Transcondylar fracture 10 months post ORIF

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

35. 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

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

37. Patellar fractures

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

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

40. Transverse Patellar Fracture

41. 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

42. 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

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

44. Patellar Fractures
After total patellectomy and repair of the extensor mechanism

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

46. 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

47. 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

48. 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)

49. 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)

50. Tibial Plateau Fractures Schatzker Classification

51. Schatzker Classification
4. Medial plateau fracture (15%)

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

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

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

55. Tibial Plateau Fracture. Type?

56. Tibial Plateau Fracture - Type?

57. 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

58. Tibial Plateau Fractures
Complications
decreased ROM
degenerative arthritis
angular deformity of knee
associated ligamentous injuries
neurovascular compromise early and late (compartment syndrome)

59. Neurovascular compromise in action
Popliteal artery occlusion following high energy bicondylar tibial plateau fracture

60. Schatzker type II and proximal fibular fracture

61. 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

62. 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

63. Tibial Spine Injury
Type II tibial spine avulsion fracture

64. 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

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

66. 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

67. Tibial tuberosity fractures
Type II tibial tuberosity fracture

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

69. 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

70. 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

71. Tibial Shaft Fracture
Closed distal third comminuted fracture of left tibia
Nondisplaced as <5% angulation, no rotation

72. 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

73. 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

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

75. 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

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

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

78. 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