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Trauma > Femoral dislocations and femoral fractures > Flashcards

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
Q

What are the advantages of using a nail?

A 
Decrease op time
decrease reoperation rate at 1 year
prevent medialisation of shaft
fewer blood transfusions
shorter hospital stay
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25
Q

What are the disadvantages of using a nail?

A

Creates a stress riser in proximal femur

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26
Q

What is normally used for fixation in intertrochanteric nof fractures?

A

DHS in stable fractures

27
Q

What is a predictor of outcome with using a DHS?

A

The tip apex distance

28
Q

Who described the tip apex distance and what is it?

A

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
Q

What are the complications of operative fixation?

A

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
Q

What are thee outcome of DHS fixation?

A

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
Q

What are subtrochanteric fractures defined as?

A

Fracture 5cm below lesser trochanter

32
Q

Who gets these?

A

Young- high energy- rta
Elderly -low energy
Rule out bisphosphonate use and pathological fractures

33
Q

What are the deforming forces around the subtrochanteric fracture?

A

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
Q

Can you describe any classification systems of subtrochanteric fractures ?

A

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
Q

What X-ray would you order with someone with a subtrochanteric fracture?

A

AP
LAt
full length femur

36
Q

What tx would you give for a subtrochanteric fracture?

A

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
Q

What position would the pt be in for an im nail and what are its advantages?

A

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
Q

What are the advantages of a cephalomeduallary nail?

A

Preserves vasulcularity
load sharing implant
stronger construct in unstable fracture pattern

39
Q

What are the disadvantages of a cephalomeduallary nail?

A

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
Q

What are the complications of s subtrochanteric fracture?

A

Varus/ procurvatum malunion

41
Q

What is the epidemiology of femoral shaft fractures?

A

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
Q

What are the associated injuries with femoral shaft fractures ?

A

Ipislateral femoral neck fracture- 6%, often basicervical, vertical and non displaced
missed !!!!

Bilateral femur fractures
significant pulmonary complications
higher rate of mortality

43
Q

What is the line aspera?

A

Rough crest of bone running down middle third of post femur attachment of various sites of muscle and fascia

44
Q

Describe what is contained in the 3 compartments of the thigh?

A

Anterior
Sartorius
Quadriceps

Posterior-
Biceps femoris
Semitendinosis
Semimembranosus

Adductor
 Gracilis
Adductor longus
 adductor brevis
  adductor magnus
45
Q

What are the deforming forces on the fracture?

A

Prox fragment- flexion- iliopoas
abduction- glut medius and minimus

distal- varus = adductors
extension= gastronemius

46
Q

Can you describe any classification systems?

A

OTA/AO
32A- A1, A2 or A3
32B- B1,B2,B3
32C- C1,C2,C3

47
Q

What tx would you give for a pt with a femoral fracture?

A

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
Q

What X-rays oudl you order?

A

AP, lateral of entire femur
AP pelvis and lateral of ipislateral hip to rule out fracture
? CT

49
Q

What tx would you give?

A

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
Q

What are the indications for antigrade im nail? what are the advantage of using this technique ?

A

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
Q

What are the indications for retrograde im nail? what are the advantage of using this technique ?

A 
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
Q

What are the indications for ex fix then im nailing 2-3 wks later?

A

unstable ppolytrauma
vascular injury
severe open fracture

53
Q

What are the indications for orif with plate in femoral shaft fractures?

A

ipislateral neck fractures requiring screw fixation
fracturea at distal metaphyseal- diaphyseal junction
inablity to access medullary canal

54
Q

What are the outcomes of orif?

A

Inferior to IM nailing
higher rate of infection
Higher rate of non union
higher rate of hardware failure

55
Q

What are the advantages of a piriformis entry point for Im nail?

A

Colinear trajectory long axis of femoral shaft

56
Q

What are the disadvantages of a piriformis entry point for Im nail?

A

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
Q

What are the advantages of a trochanteric entry point for im nail?

A

minimise soft tissue injury to abdcutors

easy starting point than piriformis

58
Q

What are the disadvantages of a trochanteric entry point for im nail?

A

not collinear with long axis of femoral shaft
must use nail specifically for this entry point
use of straight nail-> varus malalignmemt

59
Q

Is reamed nailing superior to unreamed?

A

Yes as increased union rates, decreased time to union and no increase in pulmonary complications

60
Q

what is the union rate for reamed ante grade nails?

A

98-99%

Low complication rate- infection 2%

61
Q

What are the disadvantage of ante grade nails?

A

Hetertrophic ossification higher cf retrograde
increased rate of hip pain
mismatch curvature of femoral shaft and nail-> ant perforation of nail

62
Q

What are the disadvantage of retrograde nails?

A

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
Q

what would you fix first in a ipislateral femoral neck fracture and femoral shaft fracture?

A

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
Q

What are the complications of femoral shaft fractures?

A 
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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