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Femoral dislocations and femoral fractures Flashcards

0
Q

What direction do hip dislocations go?

A

90% posterior due to hitting dash board

Right hip involved more than left

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1
Q

What is the blood supply to the femoral head?

A

Superior and posterior Cervical vessels from the medial circumflex artery ( posterior)- off profound a femoris- main supply
Ligamemtum TERES
Reticular vessels

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2
Q

What are the associated injuries with a posterior dislocation?

A 
Osteonecrosis
Post wall acetabular fractures 
Femoral head fractures 
Sciatic nerve injury
Ipsilateral knee injury- 25%
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3
Q

Heat are anterior hip dislocations associated with?

A

F work ahead impaction or chondral injury

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4
Q

What is the position of the leg in an posterior dislocation ?

A

Flexion
Adduction
Internal rotation
10-20% risk of sciatic injury

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5
Q

What position will then leg being in an anterior Discloation ?

A

Flexed, adduced and External rotation

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6
Q

What do you see on X-ray for a post dislocation ?

A

Head smaller than controlateral side

Shelton line disrupted

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7
Q

Is ct helpful?

A

Yes it helps to identity lose bodies, femoral head/acetabular fractures
Must be obtained for all ulama tic hip dislocations

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8
Q

What is the tx of a disclosed hip?

A

Emergency closed reduction within 6 hours CI- femoral neck fracture

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9
Q

When would you operate for open reduction ?

A 
Irreducible Discloation
Incarcerated fragment 
Delayed presentation
Non concentric reduction
Urgent
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10
Q

What approach do you use for a post dislocation ?

A

Posterior approach- KOCHER’s langerbeck

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11
Q

What approach would you used for an anterior Discloation ?

A

Anterior smith perversion approach

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12
Q

What is the association of femoral head fractures and dislocation of the femur? Why is that?

A

5-15%

Contact of femoral head to posterior rim of acetabulum

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13
Q

What is the classification ?

A

Pipkin

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14
Q

Ca. You describe the pipkin classification ?

A

1-fracture BELOW Ligamemtum TERES - doesn’t involve the weight bearing surface of the joint
2- fracture ABOVE Ligamemtum TERES - involves the Wb surface if the joint
3- 1 or 2 with associated femoral neck fracture
4- 1 or 2 with associated acetabular fracture

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15
Q

What are the. Tx for a femoral head fracture ?

A

Non operative- acute Dislocation- post op ct required
Pipkin 1 - toe touch weight bear 4-6 weeks with restricted adduction and internal rotation- serial X-rays to maintain reduction

Operative
PIPKIN 2 with >1mm step off
If removing loose bodies in Bodies joint
Associated neck or acetabular fracture pipkin 3 /4
Pipkin 4- small post wall acetabular fractures can be tx non op

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16
Q

What are the outcomes of femoral head fracture?

A

Poorer outcome with post approach and use of 3.0mm cannulated screws with washers

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17
Q

What surgical approach would you use for a pipkin fracture ?

A

Pipkin 1-3 anterior approach - smith peterson

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18
Q

What fixation method would you use to secure the head ?

A

2 ore more 2.7mm or 3.5 mm lag screws

Countersink the heads to prevent heard prominence

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19
Q

What would your post op regime be?

A

Mobilisation- early rom- strengthen quads and abductors
Delay bw for 4-6 weeks
X-ray 6 months to see if avn and osteoarthritis

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20
Q

What would your mx be for pipkin 4? Why?

A

ORIF of femoral head with greater trochanter OSTEOTOMY with glut medius attached using posterior approach
Best to visualise femoral head fracture and ascetabulum post wall fractures
Preserves medial circumflex artery
Unitised plane between glut max- no internervous plane( receives it nerve supply medial to split)

Or Arthroplasty- either posterior better
Can allows immediate post op wb and mobilisation

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21
Q

What are the complications of femoral head fractures ?

A

Heterotrophic ossification 6-64%, > in anterior vs post approach . Use radiation therapy if concern especially if head injury

Avn- 0-23%, greater if longer time taken for reduction

Sciatic nerve neuroproaxia

Degenerative joint disease - 8-75% due to incongruent and cartilage damage

Decreased internal rotation

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22
Q

What intertrochanteic fractures are not amenable to dhs?

A 
the unstable ones-
reverse oblique fractures
large postmedial fragment
subtrochanteric extension
they will collapse into varus or the shaft will displace medially
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23
Q

what do you use in these fracture then to aid reduction ?

A

cephalomedaullary nail- e.g. gamma nail

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24
What are the advantages of using a nail?
``` Decrease op time decrease reoperation rate at 1 year prevent medialisation of shaft fewer blood transfusions shorter hospital stay ```
25
What are the disadvantages of using a nail?
Creates a stress riser in proximal femur
26
What is normally used for fixation in intertrochanteric nof fractures?
DHS in stable fractures
27
What is a predictor of outcome with using a DHS?
The tip apex distance
28
Who described the tip apex distance and what is it?
Baumgaerter examined the factors that lead to failure of sliding hip screw- summation of the distance from the tip of screw to femoral cortex on ap and lateral . A distance of <25mm has been shown to minimise the risk of fixation cut out in stable and unstable intertrochanteric fractures
29
What are the complications of operative fixation?
Implant failure ad cut out- common ion young tx with corrective osteotomy + revision orif elderly tx with THR/Hemi Anterior perforation of the distal femur- im due to mismatch of radius of curvature of the femur ( short) and implant ( longer)
30
What are thee outcome of DHS fixation?
Surgery within 48 hours associated with decrease in 1 year mortality 4 hole plate shows no benefit or biomechanically cf 2 hole cephalomedaullary nails show no benefit over DHS in stable intertroahanteric
31
What are subtrochanteric fractures defined as?
Fracture 5cm below lesser trochanter
32
Who gets these?
Young- high energy- rta Elderly -low energy Rule out bisphosphonate use and pathological fractures
33
What are the deforming forces around the subtrochanteric fracture?
Proximal fragment- flexes- iliopsoas abducts- gluteus medius and minimus ext rotation- Short ext rotators-piriformis, obturator internus, sup and inf gamelli, quadratus femoris Distal fragment- adducts and shortens- adductors- magnus, longus and brevis
34
Can you describe any classification systems of subtrochanteric fractures ?
OTA/AO femur 3 location diaphysis 2 subtrochanteric 0.1 ``` Fracture pattern a- simple b wedge c complex so 32A3.1- transverse frac 3 32B3.1- fragmented 3 32C1.1- spiral -1 ```
35
What X-ray would you order with someone with a subtrochanteric fracture?
AP LAt full length femur
36
What tx would you give for a subtrochanteric fracture?
Observation with pain management - for pt who could not tolerate surgery due to comorbidities Operative IM nail usually cephalomedullary nail fixed angle plates- assoc with neck factures
37
What position would the pt be in for an im nail and what are its advantages?
Lateral positioning- easier reduction of distal fragment to the flexed prix fragment . easier portal entry, esp in piriformis entry nails Supine position- protective to the injured spine, address other injuries in polytrauma pt, easier assess to rotation
38
What are the advantages of a cephalomeduallary nail?
Preserves vasulcularity load sharing implant stronger construct in unstable fracture pattern
39
What are the disadvantages of a cephalomeduallary nail?
sometimes technically difficult nail not be used to aid reduction so may have to open fracture to gain reduction mismatch of radius and curvature ( straighter) can lead to perforation of the anterior cortex of distal femur piriformis entry point may migate risk of iatrogenic malediction from proximal valgus bend on trochanteric entry nail- therefore go as medial as possible
40
What are the complications of s subtrochanteric fracture?
Varus/ procurvatum malunion
41
What is the epidemiology of femoral shaft fractures?
Incidence of 37.1 per 100,000 person/pa high energy trauma frequently associated with life threatening conditions- common in young low energy- common elderly after a fall
42
What are the associated injuries with femoral shaft fractures ?
Ipislateral femoral neck fracture- 6%, often basicervical, vertical and non displaced missed !!!! Bilateral femur fractures significant pulmonary complications higher rate of mortality
43
What is the line aspera?
Rough crest of bone running down middle third of post femur attachment of various sites of muscle and fascia
44
Describe what is contained in the 3 compartments of the thigh?
Anterior Sartorius Quadriceps Posterior- Biceps femoris Semitendinosis Semimembranosus ``` Adductor Gracilis Adductor longus adductor brevis adductor magnus ```
45
What are the deforming forces on the fracture?
Prox fragment- flexion- iliopoas abduction- glut medius and minimus distal- varus = adductors extension= gastronemius
46
Can you describe any classification systems?
OTA/AO 32A- A1, A2 or A3 32B- B1,B2,B3 32C- C1,C2,C3
47
What tx would you give for a pt with a femoral fracture?
Initial evaluation using the ATLS correcting an life threatening injuries Document leg appearance, NVI and exam for ipisalt femoral fracture - often difficult due to pain froom first fracture
48
What X-rays oudl you order?
AP, lateral of entire femur AP pelvis and lateral of ipislateral hip to rule out fracture ? CT
49
What tx would you give?
Non op- undisplaced fractures in pt with multiple comorbidities ``` Operative- antegrade reamed IM nail can use retrograde reamed im nail ex -fix with conversion to im nail in 2-3 wks orif with plate ```
50
What are the indications for antigrade im nail? what are the advantage of using this technique ?
Gold standard for tx of diaphyseal fractures stabilse within 24 hours decrease pulmonary complications - ards decrease thromembolic events improve rehab decrease length of stay and cost of hospitalisation The exception is the pt with closed head injury- aim then to avoid hypotension and hypoxemia consider provisional fixation - damage control
51
What are the indications for retrograde im nail? what are the advantage of using this technique ?
``` ipislateral femoral neck fracture ipsilateral tibial shaft fracture ipsilateral acetabular fracture- doesn't compromised surgical approach to acetabulum multiple system trauma bilateral femoral fractures- avoid repositioning morbid obesity pregancy outcomes are comparable to ante grade ```
52
What are the indications for ex fix then im nailing 2-3 wks later?
unstable ppolytrauma vascular injury severe open fracture
53
What are the indications for orif with plate in femoral shaft fractures?
ipislateral neck fractures requiring screw fixation fracturea at distal metaphyseal- diaphyseal junction inablity to access medullary canal
54
What are the outcomes of orif?
Inferior to IM nailing higher rate of infection Higher rate of non union higher rate of hardware failure
55
What are the advantages of a piriformis entry point for Im nail?
Colinear trajectory long axis of femoral shaft
56
What are the disadvantages of a piriformis entry point for Im nail?
Starting point more difficult to access in obese pt Cause most significant abductor muscle and tendon damage-> abductor limp Blood supply to femoral head-> AVN in paeds pt
57
What are the advantages of a trochanteric entry point for im nail?
minimise soft tissue injury to abdcutors | easy starting point than piriformis
58
What are the disadvantages of a trochanteric entry point for im nail?
not collinear with long axis of femoral shaft must use nail specifically for this entry point use of straight nail-> varus malalignmemt
59
Is reamed nailing superior to unreamed?
Yes as increased union rates, decreased time to union and no increase in pulmonary complications
60
what is the union rate for reamed ante grade nails?
98-99% | Low complication rate- infection 2%
61
What are the disadvantage of ante grade nails?
Hetertrophic ossification higher cf retrograde increased rate of hip pain mismatch curvature of femoral shaft and nail-> ant perforation of nail
62
What are the disadvantage of retrograde nails?
knee pain increased rate of interlocking screw irruption cartilage injury cricuate ligament injury Union rates similar to ante grade must inert nail with knee in 30-50 degrees flexion no increased rates of septic knee with thic technique
63
what would you fix first in a ipislateral femoral neck fracture and femoral shaft fracture?
The compression screw for neck first then retrograde nail for the shaft less preferable ante grade nail with scows anterior ro nail- technically challenging
64
What are the complications of femoral shaft fractures?
``` HO Pudenal nerve injury-10% traction femoral artery or nerve injury- rare malunion-prox 30%, distal 10% Delayed union nonunion-<1% weakness- quads and abdcuctors Iatrogenic fracture etiologies- failure to oveream canal by 0.5mm, ante grade starting point 6mm nat to intrmedullary axis ```

Trauma (16 decks)

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