lower limb fractures and dislocations Flashcards
most common proximal femoral fracture
typically intracapsujlar neck of femur fracture
who is at risk of a NOF
can be caused by relatively minor trauma in elderly (osteoporosis)
features of NOF 3
pain
shortened and externally rotated leg
may be able to walk with difficulty
define intracapsula nof
occur just below femoral head to the insertion of the capsule of the hip joint
types of intracapsular nof 3
subcapital (commonest)
transcervical
basicervical
what is the risk with intracapsular nof
higher incidence of avasuclar necrosis
manageemtn of intracapsular nof 4
minimal displacement- internal fixation in situ
-if major illness-> hemiarthoplasty
displaced fracture
-if <70yo and fit-> reduction and internal fixation
-if older and reduced mobility- hemiartho or THR
what is the primary blood supply for the femoral head
retinacular arteries from the medial and lateral femoral circumflex arteries
-arises from profunda femoris artery
what increases risk of avascular necrosis in a nof
if intracapsular nof and sufe (slipped upper femoral epiphysis)
risk of AVN <10% if undisplaced
- >80% if displaced
SURGERY SHOULD BE PERFORMED ON DAY OR DAY AFTER ADMISSION
describe the gardner classification for intracapsular femoral neck fractures
Correlates with prognosis
-Key is to differentiate between undisplaced (I & II) & displaced (III & IV)
I = Stable fracture with inferior cortex intact
II = Complete undisplaced # through the neck
III = Complete neck # with partial displacement
IV = Fully displaced #
where is an extracapsular nof defined
between insertion of hip joint capsule and 5cm below the lesser trochanter
*-blood supply is not interrupted so risk of ANV is rarer
types of extracapsular nof 2
trochanteric
subtrochanteric
management of extracapsular nof
dynamic hip screw
subtrochanteric hip fracture
-intramedullary hip screw
overview of complications with femoral shaft fracture 4
requires considerable force so look for other injuries
500-1500ml of blood lost in a simple fracture
check distal pulses for possible femoraly artery damage
sciatic nerve injury may occur
treatment of femoral shaft fracture 3
stabilise patient in ED and traction with a thomas splint
fluid resuscitate if needed
definitive treatment is with a locked intramedullary nail
-allows early mobilisation
main cause of hip dislocation
mostly by direct trauma like RTA
-extremely painful
-may be associated with other fractures and life threatening injuries
diagnosis of hip dislocation
prompt diagnosis and approparte managemnt important to reduce morbidity
early MRI diagnosis may prevent later equinus foot defmoritiy
types of hip dislocation
posterior - most common 90%
anterior
presenation of posterior hip dislocation 2
affected leg is shortened, adducted and internally rotated
femoral head can be felt in buttock
presentation of anterior hip dislocation 2
usually abducted and externally rotated
NO leg shortening
managemnt of hip dislocation 5
ABCDE approach
analgesia
reduction under GA within 4hrs to reduce risk of AVN
traction for three weeks promotes joint capsule healing
physio long term
define distal femoral and proximal tibial fractures
divided into extra and intra articular fractures
important point about distal femoral and proximal tibial fractures intracapsual
intracapsualar fractrues require fixation with an anatomically contoured locking plate
overview of tibial plateau fracture
all intra-articular and difficult to treat
have a schaztzker classification system
non-operative treatment in the elderly
internal fixation to restore articular surface and minimise later OA
hinged cast braces locked in extension can reduce risk of chronic flexure contraction
cause of patellar dislocation 1
most commonly a primary traumatic event
-direct trauma
movement that causes patellar dislocation
severe contraction of quadriceps with knee strechted in valgus and external rotation
typically lateral dislocation
-flexed knee with lateral deformity
risk factors for patellar dislocation 3
genu valgum
tibial torsion
high riding patella
imaging in patellar dislocation 1
skyline XR of patella are needed
-can be clinically obvious
treatment of patellar dislocation 4
reduction with firm medial pressure while extending the knee
post reduction XR to check for patellar fracture
period of immobilization in cast/ splint
rehab w quad strengthening exercise
define stable and unstable ankle fractures
stable- only involve one side of the ankle
-Wever A/B
unstable-he ankle joint itself is displaced or can be displaced when it is subject to normal forces
management of stable or minimally displaced ankle fracture
stable or minimally displaced fractures may be treated non-operatively in a cast
management of unstable or displaced fractures
require surgery
-compression plate
how does the weber classification for ankle fracture work
defines ankle fractures by the level of fibula fracture relative to the tibiofibular syndesmosis
define weber type A
below the syndesmosis
define weber type B
fractures start at level of the syndemosis
define weber type C
above the syndesmosis
when is an ankle XR only required in a suspected fracture 4
any pain in the malleolar zone & any of the following:
-bony tenderness at lateral malleolar zone
-bone tenderness at medial malleloar zone
-inability to weight-bear (immediately after injury & in ED)
define a maisonneuve fracture 3
proximal spiral fibula fracture with syndesmosiss rupture
-medial malleous fracture or deltoid ligament rupture
always examine proximal fibula with ‘ankle sprains’
treatment is surgical as fractures are unstable and require fixation to restore ankle mortise
define a lisfranc fracture dislocation at 1st tarsometatarsal joint
commonly missed fracture in multitrauma patients
can occur by stepping awkwardly off kerb
can cause compartment syndrome of medial foot
-later arthritis and perisitnet pain
On foot XR look for widening of the gap between medial cuneiform & base of 2nd metatarsal
-MRI gives better view
-Treat with precise anatomic reduction with screw fixation across 2nd metatarsal joint
-Lisfranc joint
define fracture neck of talus
can occur after forced dorsiflexion
serious injury because interripton of vessels may lead to AVN of talus body
displaced fractures require ORIF
define calcaneus fracture
often bilateral
known as lovers fracture (cheater jumping out the window)
frequently poor outcome
ALWAYS look for assoc spinal fracture
signs included sweling, bruising and inability to weight bear
define 2nd metatarsal fracture
look for lisfranc dislocations
usually heals well with non-operative cast and weightbearing as pain allows
define 5th metatarsal fracture
proximal avulsion fracture typically associated with ankle inversion
-treat conservatively
jones fracture
-transverse fracture near the base
-requires surgical intervention due to risk of non-union
complications of hip fractures
fracture fixation can fail if poorly done
-ensure screws and plates secured and proper position
hemiarthoplasy may dislocate if ptx falls or if capsule gives way
mobile patient to avoid
-DVT
-chest infection
-pressure sores
post-op hip fracture managemnt 5
require assistance to mobilise
physiotherapies
OT
care of elderly medicine team
home care
-ptx may not be able to return home
define a DEXA scan
measurement taken at lumbar spin and hip
gives a t-score
assessed against health adult age 30
how is a DEXA can result interpretted
higher T-score indicates lower bone density
-can calculate fracture risk
T score of -1.0 means bone mass of one standard deviation below that of young reference population
Z score is adjusted for age, gender and ehtnic factors
REMEMBER:
> -1= normal
-1 to -2.5 = osteopenia
<-2.5= osteoporosis
what is the pelvis made of up
sacrum posteriorly
ilium
ischium
pubis
differentiate between low and high energy pelvic fractures
high energy
-usually from RTA/ fall from height
-V dangerous high mortaillty rate
-high risk of bleeding and risk of damage to pelvic structures
low energy
elderly
-often osteoporotic
-low energy
-stable
-low blood loss
managemnt of low energy pelvic fractures
non-operative
mobilisation with analgesia
normally heal spoppntaneously
management of high energy pelvic fractures
stabilse to rpevent blood loss
-use pelvic binder until definitive stabilisation
-fractures can be fixed definitively with plates/bolts
three types of pelvic fracture 3
AP compression
lateral compression
vertical shear
what is important to note with high energy pelvic fractures
always nood for 2nd site of injury
pelvic ring usually breaks in 2 places
