Femoral and Tibial Fractures Flashcards
What is the typical mechanism/aetiology of femoral and tibial fractures?
• SHAFT FRACTURES USUALLY HIGH ENERGY
INJURIES E.G. RTA, FALL FROM HEIGHT,
SPORT (TIBIAL FRACTURES)
• METAPHYSEAL FRACTURES EITHER HIGH
ENERGY IN YOUNG PATIENTS, OR LOW
ENERGY IN ELDERLY/OSTEOPOROTIC
PATIENTS
Outline the initial clinical assessment of femoral and tibial fractures.
- N/V STATUS (INCLUDING PULSES)
- ASSESS FOR SHOCK (DUE TO HIGH BLOOD LOSS INTO FRACTURE SITES EVEN IN CLOSED INJURIES) , OR FAT EMBOLISM, INCLUDING ARTERIAL BLOOD GAS & ROUTINE BLOODS.
- SPLINT ASAP (THOMAS SPLINT FOR FEMUR, BACKSLAB FOR TIBIA) TO MINIMISE RISK OF COMPLICATIONS & SHOCK
- OPEN/CLOSED: OPEN INJURIES ARE MOST COMMON IN TIBIAL FRACTURES & NEED URGENT TREATMENT AS PER BOA/BAPRAS GUIDELINES
• OTHER INJURIES IN SAME LIMB
– E.G. MENISCUS/LIGAMENT INJURY WITH TIBIAL PLATEAU FRACTURE, FEMORAL NECK FRACTURE WITH FEMORAL SHAFT FRACTURE
• OTHER SITES OF INJURY (E.G. ATLS IN POLYTRAUMA)
What are the main complications of femoral and tibial fractures?
- SHOCK FROM BLOOD LOSS
- N/V DAMAGE
- FAT EMBOLISM (FEMORAL SHAFT)
- DVT/PE
- COMPARTMENT SYNDROME (ESPECIALLY TIBIA)
- DELAYED/MAL/NON-UNION
- WOUND PROBLEMS /INFECTION, ESPECIALLY IN OPEN FRACTURES
- JOINT STIFFNESS/ARTHRITIS, ESPECIALLY IN INTRA-ARTICULAR FRACTURES.
What imaging is appropriate in femoral and tibial fractures?
- Femur: AP & lateral X-rays
- Tibia & fibula: AP & lateral X-rays
- (always include joint above & below)
• +/- CT scans in comminuted intra-articular
fractures
Is angulation allowed in tibial and femoral fractures?
NO, angulation in shafts of tibia & femur not
acceptable due to weight-bearing axis of bone
disrupted
Why must tibial and femoral fractures be reduced perfectly?
They are intra-articular fractures and must be reduced
perfectly; usually with ORIF
Outline conservative management of tibial shaft fractures.
- <50% displacement acceptable
- <5 degrees varus/valgus angulation acceptable
- 6 weeks non-weightbearing in long leg cast
- Then 6 weeks partial weight-bearing in PTB cast
- Then weight-bear as tolerated out of cast
Outline the management of tibial shaft fractures.
Undisplaced: No reduction required and maintained with long leg cast
Displaced: MUS closed
reduction maintained with long leg cast (but if initially
displaced probably unstable)
GA MUA closed reduction, intra-medullary (IM) nail, or external fixator (if soft tissue damage or highly comminuted)
GA MUA Open reduction (OR) Internal fixation (IF)
(more for fractures near joint e.g. lateral plateau fracture, due to poor soft tissue coverage over mid-shaft)
Outline the management of open fractures.
• Treatment now as per BOA/BAPRAS guidelines
• High risk of contamination if farm/marine contaminant
• Give IV co-amoxiclav early, dress wound & splint
• Within 24 hours take to theatre, wash, debride,
stabilise fracture, +/- close defect (may need plastic surgeons)
– IM nail can be used for grades I-IIIa, external fixator
for IIIb & IIIc (although IIIc often results in amputation)
Describe compartment syndrome.
- Most common in closed fractures- up to 20%
- Most commonly deep posterior compartment followed by anterior
- Deep posterior- weakness toe flexion/ankle eversion, pain on passive toe extension and diminished sensation sole of foot
- Anterior- weakness of toe extension, pain on passive toe flexion and diminished sensation in 1st web space
- Treated by urgent fasciotomies (realign limb, release tight dressings and plasters, involve senior help ASAP)
How are femoral fractures (excluding hip fractures) managed?
- GA closed reduction maintained with intramedullary nail is most common.
- GA ORIF (uncommon for shaft fractures but common in distal femoral fractures e.g. intra-artic)
Outline the clinical signs of fat embolism.
• Asymptomatic period of 12-28 hours • Respiratory failure and embolic phenomena which can lead to death • Tachycardia, tachypnea, pyrexia, hypoxemia, hypocapnia, thrombocytopaenia, and confusion • Petechial rash – late • NB/Treatment = supportive (ICU)
