fractures Flashcards
femoral neck fractures
garden classification-( based on AP pelvis X-ray)
blood supply- medial circumflex fem, (lateral epiphyseal artery)
X-ray views- AP pelvis and cross table lateral, contralateral full length femur (for template)
—traction internal rotation AP best for defining fracture
fem neck fx treatment
non opp- non ambulatory pts, those with contraindications to surf
opp-ORIF
- Cannulated screws- non displaced fx, Garden 1 and 2, or displaced tranccervical fx in young patient ( surgical emergency to limit vascular insult)
- –three screws inverted triangle
- sliding hip screw-basicervical, vertical fx pattern in young patients( biomech superior to canulated screw)
- hemi
- total is preexisting arthritis
fem neck fx classification
Garden( based off AP pelvis) guides treatment
type 1- incomplete or valgus impacted
type 2- complete fx non displaced
type 3- complete fx, partial displacement ( trabecular lines don’t line up)
type 4- complete fx , fully displaced ( (trabecular lines will line up)
Pauwels- guides treatment in younger patients
1- < 30 degree from horizontal
2- 30-50 degree from horizontal
3- >50 degrees from horizontal
—more vertical fractures better treated with SHS
inter trochanteric fractures
- RF
- important anatomy
- classification
- xrays
RF=proximal humerus fractures increase risk for 1 year
calcar femorale- vertical wall of dense bone that extends from posteromedial aspect of femoral shaft to posterior portion of femoral neck, used to determine stability
classification- Evans - stable vs unstable
unstable= combination of post medial cortex, sub troch extension, reverse obliquity, lateral wall blowout, Handbook also says basicervical
X-rays- AP pelvis, AP hip, Cross table lateral, full length femur, physician assisted internal rotation for better classification
inter trochanteric fractures treatment
Sliding hip screw in stable inter troch, TAD should be less than 25mm
IM nail - indicated in stable and unstable fx, reverse obliquity, sub trochanteric extension, lateral wall blowout
implant failure 60% with TAD >45mm
sub trochanteric fx
lesser trochanter to 5cm below
epi- usually high energy
- bisphosphonate use is RF especially alendronate
-deforming forces-
—-proximal abduction, flexion and External Rotation via glute med/minimus, iliopsoas, short external rotaters respectively
-distal frag
—adduction and shortening via abductors
Classification: Russel taylor classification based on extension into performs fossa
Xrays- AP and lateral hip, ap pelvis, traction views to classify fx
treatment- IM nail
also fix angle blade plating( lateral approach)
bisphosphonate related sub troch fractures
lateral cortical thickening
transverse fracture orientation
medial spike
lack of comminution
Russel Taylor classification
sub trochanteric fractures
- Type 1 fx with intact piriformis fossa
- –A= lesser troch attached to proximal segment
- –B =leser trochdetached from proximal segment
- Type 2 fx extend into the performs fossa
- –A stable posterior medial cortex
- –Bcommunition of performs fossa and lesser torch, associated with femoral shaft combination
treatment
• Historically used to differentiate between fractures that would amenable to an intramedullary nail (type I) and those that required some form of a lateral fixed angle device (type II)
• Current interlocking options with both trochanteric and piriformis entry nails allow for treatment of type II fractures with intramedullary implants
femoral shaft fractures
compartments
deforming forces
imaging
3 compartments of thigh
- ant- sartorius and quads
- post- biceps femoris, semitendinosis and membranosus
- adductor- gracillis, adductor longus, brevis, magnus
deform forces
- proximally abduction via glute med.minimus, flexed via iliopsoas
- distally- varus via adductors on distal femur, extension via gastroc, and shortening via hamstrings
fem neck fx missed 19-33 % of time present
xray
- AP and LAT of entire femur
- AP/LAT ipsilateral hip( fem neck fx must rule out), AP/lat of ipsilateral knee
Femoral shaft fx classification
- descriptive classification
- Winquist and Hansen based on fx comminution
- -0-no comminution
- -1- minimal comminution
- -2- cortices of both fragments at least 50% intact
- -3- 50-100% cortical ommunition ( less than 50% cortices intact)
- -4-Segmental fracture with no contact between proximal and distal fragment ( circumferential comminution)
Femoral shaft fx treatment
non opp
-nondisplaced fx in pt with multiple med problems
OPP
- GOLD STANDARD- antegrade reamed IM nail
- -treat w/in 24h decreases ARDS, PE, length of stay and improves rehab
- Retrograde reamed IM nail
- -indicated in ipsilateral fem neck fx, floating knee, ipsilat acetabular fx
- ex fix- then conversion to IM nail in2-3 wk
- -polytrauma patients
- plate fixation associated with infection, nonunion, hardware failure
wolff’s law
Bony structures orient themselves in form and mass to best resist extrinsic forces (ie, form and mass follow function)
