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Lower extremity trauma 1
The document discusses various types of lower extremity trauma including fractures of the hip, femur, knee, tibia, and ankle. For each injury, the document describes the mechanism of injury, classification systems, treatment options, and important clinical considerations. Management involves restoring anatomy, protecting soft tissues, preventing complications, and allowing for early mobilization depending on the specific fracture pattern and patient factors.
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Introduction to lower extremity trauma with specific types including hip, femur, knee, tibia, and ankle fractures.
Classification of hip fractures including dislocations, with epidemiology showing 250,000 annual hip fractures expected to double by 2050.
Management of hip dislocations via closed reduction techniques to prevent complications like avascular necrosis.
Concurrent injuries with hip dislocation and Pipkin classification for treating femoral head fractures.
Classification of femoral neck fractures (Garden System) with treatment options differing for young versus elderly.
Details on intertrochanteric femur fractures, their classification and treatment based on stability.
Classification and treatment methods for subtrochanteric femur fractures and femoral shaft fractures.
Distal femur fractures' treatments and associations with ligamentous and vascular knee injuries.
Causes and evaluation of patella fractures along with treatment options based on extensor mechanism integrity.
Overview of different types of tibia fractures including plateau fractures, classification systems, and treatment.
Examples of injury management techniques for tibial plateau fractures, stressing soft tissue evaluation.
Management steps for tibial shaft fractures including open fractures, fixation methods, and outcomes.
Severity and treatment strategies of tibial pilon fractures with focus on restoring surfaces and managing complications.
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Lower extremity trauma 1
- 1. LOWER EXTREMITY TRAUMA By…. Dr.Muhammad Salman Khan
- 2. Lower Extremity Trauma Hip Fractures / Dislocations Femur Fractures Patella Fractures Knee Dislocations Tibia Fractures Ankle Fractures
- 3. Hip Fractures HipDislocations Femoral Head Fractures Femoral Neck Fractures Intertrochanteric Fractures Subtrochanteric Fractures
- 4. Epidemiology 250,000 Hipfractures annually Expected to double by 2050 At risk populations Elderly: poor balance & vision, osteoporosis, inactivity, medications, malnutrition Young: high energy trauma
- 5. Hip Dislocations Significanttrauma, usually MVA Posterior: Hip flexion, Hip Internally Rotated & Adducted Anterior: Limb in Flexion, External Rotation, Abduction
- 6. Hip Dislocations EmergentTreatment:Closed Reduction Dislocated hip is an emergency Goal is to reduce risk of Avascular Necrosis and Degenrative Joint Disease Allows restoration of flow through occluded or compressed vessels Literature supports decreasedAVN with earlier reduction Requires proper anesthesia Requires “team” (i.e. more than one person)
- 7. Hip Dislocations EmergentTreatment:Closed Reduction General anesthesia with muscle relaxation facilitates reduction, but is not necessary Conscious sedation is acceptable Attempts at reduction with inadequate analgesia/ sedation will cause unnecessary pain, cause muscle spasm, and make subsequent attempts at reduction more difficult
- 8. Hip Dislocations EmergentTreatment:Closed Reduction Allis Maneuver Assistant stabilizes pelvis with pressure on Ant. Sup. Iliac Spine Surgeon stands on stretcher and gently flexes hip to 90deg, applies progressively increasing traction to the extremity with gentle adduction and internal rotation Reduction can often be seen and felt Insert hip Reduction Picture
- 9. Hip Dislocations FollowingClosed Reduction Check stability of hip to 90deg flexion Repeat X Ray Pelvis AP Judet views of pelvis (if acetabulum fx) CT scan with thin cuts through acetabulum Remains of bony fragments within hip joint (indication for emergentOR trip to remove incarcerated fragment of bone)
- 10. Femoral Head Fractures Concurrent with hip dislocation due to shear injury
- 11. Femoral Head Fractures Pipkin Classification I: Fracture inferior to fovea II: Fracture superior to fovea III: Femoral head + acetabulum fracture IV: Femoral head + femoral neck fracture
- 12. Femoral Head Fractures Treatment Options Type I Nonoperative: non-displaced ORIF if displaced Type II: ORIF Type III: ORIF of both fractures Type IV: ORIF vs. hemiarthroplasty
- 13. Femoral Neck Fractures Garden Classification I Valgus impacted II Non-displaced III Complete: Partially Displaced IV Complete: Fully Displaced Functional Classification Stable (I/II) Unstable (III/IV) I II III IV
- 14. Femoral Neck Fractures Treatment Options Non-operative Very limited role Activity modification Skeletal traction Operative ORIF Hemiarthroplasty (Endoprosthesis) Total Hip Replacement
- 15.
- 16. Femoral Neck Fractures Young Patients UrgentORIF (<6hrs) Elderly Patients ORIF possible (higher risk AVN, non-union, and failure of fixation) Hemiarthroplasty Total Hip Replacement
- 17. Intertrochanteric Hip Fx Intertrochanteric Femur Fracture Extra-capsular femoral neck To inferior border of the lesser trochanter
- 18. Intertrochanteric Hip Fx Intertrochanteric Femur Fracture Physical Findings: Shortened / ER Posture Obtain Xrays: AP Pelvis, Cross table lateral
- 19. Intertrochanteric Hip Fx Classification # of parts: Head/Neck, GT, LT, Shaft Stable Resists medial & compressive Loads after fixation Unstable Collapses into varus or shaft medializes despite anatomic reduction with fixation Reverse Obliquity
- 20.
- 21. Intertrochanteric Hip Fx Treatment Options Stable: Dynamic Hip Screw (2-hole) Unstable/Reverse: Intra Medullary Recon Nail
- 22. Subtrochanteric Femur Fx Classification Located from LT to 5cm distal into shaft Intact Piriformis Fossa? Treatment IM Nail Cephalomedullary IM Nail ORIF
- 23. Femoral Shaft Fx Type 0 - No comminution Type 1 - Insignificant butterfly fragment with transverse or short oblique fracture Type 2 - Large butterfly of less than 50% of the bony width, > 50% of cortex intact Type 3 - Larger butterfly leaving less than 50% of the cortex in contact Type 4 - Segmental comminution Winquist and Hansen 66A, 1984
- 24. Femoral Shaft Fx Treatment Options IM Nail with locking screws ORIF with plate/screw construct External fixation Consider traction pin if prolonged delay to surgery
- 25. Distal Femur Fractures Distal Metaphyseal Fractures Look for intra-articular involvement Plain films CT
- 26. Distal Femur Fractures Treatment: Retrograde IM Nail ORIF open vs. MIPO Above depends on fracture type, bone quality, and fracture location
- 27. High associationof injuries Ligamentous Injury ACL, PCL, Posterolateral Corner LCL, MCL Vascular Injury Intimal tear vs. Disruption Obtain ABI’s (+) Arteriogram Vascular surgery consult with repair within 8hrs Peroneal >>Tibial N. injury Knee Dislocations
- 28. Patella Fractures History MVA, fall onto knee, eccentric loading Physical Exam Ability to perform straight leg raise against gravity (ie, extensor mechanism still intact?) Pain, swelling, contusions, lacerations and/or abrasions at the site of injury Palpable defect
- 29. Patella Fractures Radiographs AP/Lateral/Sunrise views Treatment ORIF if ext mechanism is incompetent Non-operative treatment with brace if ext mechanism remains intact
- 30. Tibia Fractures ProximalTibiaFractures (Tibial Plateau) Tibial Shaft Fractures DistalTibia Fractures (Tibial Pilon/Plafond)
- 31. Tibial Plateau Fractures MVA, fall from height, sporting injuries Mechanism and energy of injury plays a major role in determining orthopedic care Examine soft tissues, neurologic exam (peroneal N.), vascular exam (esp with medial plateau injuries) Be aware for compartment syndrome Check for knee ligamentous instability
- 32. Tibial Plateau Fractures Xrays: AP/Lateral +/- traction films CT scan (after ex-fix if appropriate)
- 33. Schatzker Classificationof Plateau Fxs Lower Energy Higher Energy
- 34. Tibial Plateau Fractures Treatment Spanning External Fixator may be appropriate for temporary stabilization and to allow for resolution of soft tissue injuries Insert blister Pics of ex-fix here
- 35. Tibial Plateau Fractures Treatment Definitive ORIF for patients with varus/valgus instability, >5mm articular stepoff Non-operative in non- displaced stable fractures or patients with poor surgical risks
- 36. Tibial Shaft Fractures Mechanism of Injury Can occur in lower energy, torsion type injury (e.g., skiing) More common with higher energy direct force (e.g., car bumper) Open fractures of the tibia are more common than in any other long bone
- 37. Tibial Shaft Fractures Open Tibia Fx Priorities – ABC’S – Associated Injuries – Tetanus – Antibiotics – Fixation
- 38. Management ofOpen Fx SoftTissues ER: initial evaluation wound covered with sterile dressing and leg splinted, tetanus prophylaxis and appropriate antibiotics OR:Thorough I&D undertaken within 6 hours with serial debridements as warranted followed by definitive soft tissue cover Tibial Shaft Fractures
- 39. Tibial Shaft Fractures Definitive Soft Tissue Coverage – Proximal third tibia fractures can be covered with gastrocnemius rotation flap – Middle third tibia fractures can be covered with soleus rotation flap – Distal third fractures usually require free flap for coverage
- 40. Tibial Shaft Fractures Treatment Options IM Nail ORIF with Plates External Fixation Cast
- 41. Advantages ofIM nailing Lower non-union rate Smaller incisions Earlier weightbearing and function Single surgery Tibial Shaft Fractures
- 42. IM nailingof distal and proximal fx Can be done but requires additional planning, special nails, and advanced techniques Tibial Shaft Fractures
- 43. Fractures involvingdistal tibia metaphysis and into the ankle joint Soft tissue management is key! Often occurs from fall from height or high energy injuries in MVA “Excellent” results are rare, “Fair to Good” is the norm outcome Multiple potential complications Tibial Pilon Fractures
- 44. Initial Evaluation Plain films, CT scan Spanning External Fixator Delayed Definitive Care to protect soft tissues and allow for soft tissue swelling to resolve Tibial Pilon Fractures
- 45. Tibial Pilon Fractures Treatment Goals RestoreArticular Surface Minimize SoftTissue Injury Establish Length AvoidVarus Collapse Treatment Options IM nail with limited ORIF ORIF External Fixator
- 46. Tibial Pilon Fractures Complications Mal or Non-union (Varus) SoftTissue Complications Infection PotentialAmputation