Lower limb trauma Flashcards
Femoral shaft fracture
High energy injuries frequently associated with life-threatening conditions
- Incidence = ____per 100,000 person-years
- Mechanism
3, Associated conditions
- 37.1 per 100,000 person-years
- Traumatic
◾high-energy (most common in younger population; often a result of high-speed MVA)
◾low-energy (more common in elderly eg.fall from standing) - Associated conditions
i) ipsilateral femoral neck fracture
◾2-6% incidence
◾often basicervical, vertical, and nondisplaced
◾missed 19-31% of time
ii) Bilateral femur fractures
◾significant risk of pulmonary complications
◾increased rate of mortality as compared to unilateral fractures
Femoral shaft fracture
Anatomy
Osteology of femur
◾largest and strongest bone in the body
◾femur has an anterior bow
◾linea aspera
◦ rough crest of bone running down middle third of posterior femur
◦ attachment site for various muscles and fascia
◦ acts as a compressive strut to accommodate anterior bow to femur
Femoral shaft fracture
3 compartments of the thigh
i. anterior (muscles and nerve)
ii. posterior (muscles and nerve
iii. adductor (muscles and nerve)
i. Anterior ◾sartorius ◾quadriceps (femoral)
ii. Posterior ◾biceps femoris ◾semiT ◾semimem (sciatic)
iii. Adductor ◾gracilis ◾adductor longus ◾adductor brevis ◾adductor magnus (Obturator)
Femoral shaft fracture: Biomechanics
Deforming force after fracture
- proximal fragment
- distal segment
- Proximal fragment
◾abducted : gluteus medius and minimus abduct as they insert on greater trochanter
◾flexed: iliopsoas flexes fragment as it inserts on lesser trochanter - Distal segment
◾varus : adductors inserting on medial aspect of distal femur
◾extension : gastrocnemius attaches on distal aspect of posterior femur
Femoral shaft fracture
Classification
Winquist and Hansen Classification
Type 0 • No comminution
Type I • Insignificant amount of comminution
Type II • Greater than 50% cortical contact
Type III • Less than 50% cortical contact
Type IV • Segmental fracture with no contact between proximal and distal fragment
Femoral shaft fracture: Presentation
NOTE: Initial evaluation ATLS should be initiated
Physical exam
- Inspection
- Blood loss in closed femoral shaft fractures is ___ to ____ mL
- For closed tibial shaft fractures, ____to____
- Blood loss in open fractures may be ______ that of closed fractures
- ◾tense, swollen thigh; ◾affected leg often shortened;
◾tenderness about thigh - 1000-1500ml
- 500-1000ml
- Double
NOTE:
◾examination for ipsilateral femoral neck fracture often difficult secondary to pain from fracture
◾must record and document distal neurovascular status
Femoral shaft fracture:Treatment
Nonoperative
Treatment: Nonoperative
Long leg cast
◾indications: nondisplaced femoral shaft fractures in patients with multiple medical comorbidities
Femoral shaft fracture: Operative
Antegrade nail (reamed)
- indications
- outcomes
- gold standard for treatment of diaphyseal femur fractures
- Outcomes
a) stabilization within 24 hours is associated with ◾decreased pulmonary complications (ARDS)
◾decreased thromboembolic events
◾improved rehabilitation
◾decreased length of stay and cost of hospitalization
b) EXCEPTION is patient with a closed head injury ◾critical to avoid hypotension and hypoxemia
◾consider provisional fixation (damage control)
Femoral shaft fracture: Operative
Retrograde intramedullary nail with reamed technique
- indications
- outcomes
- Indications
◾ipsilateral femoral neck fracture
◾floating knee (ipsilateral tibial shaft fracture) -use same incision for tibial nail
◾ipsilateral acetabular fracture (does not compromise surgical approach to acetabulum)
◾multiple system trauma
◾bilateral femur fractures (avoids repositioning)
◾morbid obesity - Outcomes
◾results are comparable to antegrade femoral nails
◾immediate retrograde or antegrade nailing is safe for early treatment of gunshot femur fractures
Femoral shaft fracture: Operative
External fixation with conversion to intramedullary nail within 2-3 weeks
- indications
- indications
◾unstable polytrauma victim
◾vascular injury
◾severe open fracture
Femoral shaft fracture: Operative
ORIF with plate
- indications
- outcomes
- indications
◾ipsilateral neck fracture requiring screw fixation
◾fracture at distal metaphyseal-diaphyseal junction
◾inability to access medullary canal
2. outcomes
◾inferior when compared to IM nailing due to increased rates of:
◾infection
◾nonunion
◾hardware failure
Femoral shaft fracture: Surgical Techniques
Entry point: piriformis entry vs trochanteric
1. Piriformis - pros
- trochanteric entry -pros
- piriformis entry - pros
◾colinear trajectory with long axis of femoral shaft
(* higher AVN risk in paediatric patient) - trochanteric entry - pros
◾minimizes soft tissue injury to abductors
◾easier starting point than piriformis entry nail
Femoral shaft fracture: Surgical Techniques
Reamed vs unreamed antegrade nail
- Which is superior ? / Why (3)
- Indications for unreamed nail
- Interlocking screws : technique
- reamed nailing superior to unreamed nailing with
◾increased union rates
◾decreased time to union
◾no increase in pulmonary complications - Consider for patient with bilateral pulmonary injuries
- Interlocking screws : technique
◾computer-assisted navigation for screw placement decreases radiation exposure
◾widening/overlap of the interlocking hole in the proximal-distal direction ◾correct with adjustment in the abduction/adduction plane
◾widening/overlap of the interlocking hole in the anterior-posterior plane ◾correct with adjustment in the internal/external rotation plane
Femoral shaft fracture: Surgical Techniques
Antegrade nail
- Pros
- Cons
- Pros
◾98-99% union rate
◾low complication rate
◾infection risk 2% - Cons
◾not indicated for use with ipsilateral femoral neck fracture
◾increased rate of HO in hip abductors
◾> rate of hip pain compared with retrograde nailing
◾mismatch of the radius of curvature of the femoral shaft and intramedullary nails can lead to anterior perforation of the distal femur
Femoral shaft fracture: Surgical Techniques
Retrograde intramedullary nailing
- approach
- technique : Entry point
- approach
◾2 cm incision starting at distal pole of patella
◾medial parapatellar versus transtendinous approaches
◾nail inserted with knee flexed to 30-50 degrees - Entry point
◾center of intercondylar notch on AP view
◾extension of Blumensaat’s line on lateral (posterior to Blumensaat’s line risks damage to cruciate ligaments)
Femoral shaft fracture: Surgical Techniques
Retrograde intramedullary nailing
- pros
- cons
- pros
◾technically easier
◾union rates comparable to those of antegrade nailing
◾no increased rate of septic knee with retrograde nailing of open femur fractures - cons
◾knee pain
◾increased rate of interlocking screw irritation
◾cartilage injury
◾cruciate ligament injury with improper starting point
Femoral shaft fracture: Surgical Techniques
External fixation with conversion to intramedullary nail within 2-3 weeks
- technique
◾safest pin location sites are _______
◾__ pins should be used on each side of the fracture line - pros
- cons
- technique
◾anterolateral and direct lateral regions of the femur
◾2 pins should be used on each side of the fracture line - Pros
◾prevents further pulmonary insult without exposing patient to risk of major surgery
◾may be converted to IM fixation within 2-3 weeks as a single stage procedure - Cons
◾pin tract infection
◾knee stiffness
◾due to binding/scarring of quadriceps mechanism
Femoral shaft fracture: Surgical Technique
Special considerations
- Ipsilateral femoral neck fracture
a) prioriry
b) technique : preferred methods
c) technique : less preferred methods
Ipsilateral femoral neck fracture
a) priority goes to fixing femoral neck because anatomic reduction is necessary to avoid complications of AVN and nonunion
b) technique : preferred methods
◾screws for neck with retrograde nail for shaft
◾screws for neck and plate for shaft
◾compression hip screw for neck with retrograde nail for shaft
c) less preferred methods
◾antegrade nail with screws anterior to nail (technically challenging)
Femoral shaft fracture: Complications (11)
- Heterotopic ossification–>(incidence=25%;treatment=rarely clinically significant)
- Pudendal nerve injury–>(◦incidence=10% when using fracture table with traction)
- Femoral artery or nerve injury–>(◦incidence=rare;–>◦cause=can occur when inserting proximal interlocking screws during a retrograde nail)
- Malunion & rotational malalignment (see separate card)
- Delayed union(◦treatment◾dynamization of nail with or without bone grafting)
- Nonunion(◦incidence◾<10%;–>◦risk factors◾postoperative use of nonsteroidal anti-inflammatory drugs◾smoking is known to decrease bone healing in reamed antegrade exchange nailing for atrophic non-unions; –>◦treatment◾reamed exchange nailing)
7.Infection(◦incidence◾< 1%;–>◦treatment◾removal of nail and reaming of canal OR external fixation used if fracture not healed) - Weakness(◦quadriceps and hip abductors are expected to be weaker than contralateral side)
- Iatrogenic fracture etiologies–>(◦risk factors=◾antegrade starting point 6mm or more anterior to the intramedullary axishowever, anterior starting point improves position of screws into femoral head;◾failure to overream canal by at least .5mm)
- Mechanical axis deviation (MAD)–>(◦lengthening along the anatomical axis of the femur leads to lateral MAD
◦shortening along the anatomical axis of the femur leads to medial MAD) - Anterior cortical penetration
Femoral shaft fracture: Complications
Malunion and rotational malalignment
- Most accurately determined by the ______ method
- Decribe this
- Malrotation up to ____degrees is usually well tolerated
- Incidence
a) proximal fractures ____%
b) distal fractures ____% - Risk factors
a) use of a fracture table ______ risk of internal rotation deformities when compared to manual traction
b) fracture ______
c) ______ surgery - Treatment
a) intraop
b) postop
- Jeanmart method
- angle between a line drawn tangential to the femoral condyles and a line drawn through the axis of the femoral neck
- 15 degrees
4a. 30%
4b. 10%
- Risk factors
a) increases risk compared to manual traction
b) fracture comminution
c) night-time surgery - Treatment
a) Remove distal interlocking screws and manually correct rotation
b) Osteotomy is required
Patella Fracture
1. incidence: patella fractures account for ___% of all skeletal injuries
- male to female __:__
- most fractures occur in __to__ year olds
- high-energy dashboard injuries are associated with i, ii or iii
- Prognosis: osteonecrosis reported to occur in up to ___% but not found to affect clinical outcome
- 1%
- 2:1
- 20-50 yo
- i) femoral neck; ii) posterior wall acetabular fracture; iii) knee dislocation
- 25%
Patella Fracture
Mechanism of injury (2)
- Direct impact injury
◾occurs from fall or dashboard injury
◾causes failure in compression - Indirect eccentric contraction
◾occurs from rapid knee flexion against contracted quads muscle (causes failure in tension)
◾patella sleeve fracture
◾seen in pediatric population (8-10 year olds)
◾high index of suspicion required
Patella Fracture - Anatomy
Osteology
- Superior ___% of posterior surface covered by articular cartilage
- articular cartilage thickest in body - up to __mm
- posterior articular surface comprised of a (largest) and _b_facets separated by a c
Soft tissue attachments
4. _(a)_and (b) attach to anterosuperior margin
- quadriceps tendon comprised of 3 layers
a)
b)
c)
6.________attaches to inferior margin - Blood Supply
a) derives from anastomotic ring originating from ________arteries
b) most important blood supply to the patella is located ________
- 75%
- 10mm
- (a) lateral (largest); (b) medial; (c) vertical ridge
Soft tissue attachments
4. (a) quadriceps tendon; (b) fascia lata
5a) superficial layer formed from rectus femoris tendon
5b) middle layer: formed by vastus med. + lat. tendons
5c) deep layer: formed by vastus intermedius tendon
- patellar tendon
- Blood Supply
a) geniculate arteries
b) at the inferior pole
Patella Fracture
Classification
Can be described based on fracture pattern: ◾nondisplaced
◾displaced:
◦ step-off >2-3mm or
◦ fracture gap >1-4mm
◾ transverse
◾ pole or sleeve (upper or lower)
◾ vertical
◾ marginal
◾ osteochondral
◾ comminuted (stellate)Patella Fracture
Physical exam
- inspection
- motion
- provocative tests
1 Inspection
◾palpable patellar defect
◾significant hemarthrosis
- motion
◾unable to perform straight leg raise indicates failure of extensor mechanism (retinaculum disrupted –> can aspirate hemarthrosis and inject local anesthetic if patient unable to perform due to pain)\ - provocative tests
◾perform saline load test to rule out open fracture
Patella Fracture
XR Findings
◾fracture displacement (degree of fracture displacement correlates with degree of retinacular disruption)
◾patella alta =Insall-Salvati ratio <1 (indicates disruption of patellar tendon)
◾patella baja = Insall-Salvati ratio >1 (indicates disruption of quads tendon)
Patella Fracture
Bipartite patella - may be mistaken for patella fracture
- affects __% of population
- characteristic _______ position
- bilateral in __% of cases
- affects 8% of population
- characteristic superolateral position
- bilateral in 50% of cases
Patella # Rx
TBC
Knee Dislocation
Devastating injury resulting from high or low energy
- high-energy MOI
- low-energy MOI
- Associated with significant soft tissue disruption with ____ of ligaments generally disrupted
- Prognosis
- usually from MVC or fall from height; commonly a dashboard injury resulting in axial load to flexed knee
- often from athletic injury; generally has a rotational component; morbid obesity is a risk-factor
- 75% (3/4)
- complications frequent and rarely does knee return to pre-injury state
Knee Dislocation : Associated injuries
Vascular injury
1) __to__% in all dislocations
2) __to__% in anterior/posterior dislocations
3) due to tethering at the popliteal fossa
a) Proximal - fibrous tunnel at the _____ ?
b) Distal - fibrous tunnel at _______?
Nerve injury
4) usually ___________ (25%)
5) _______ nerve injury is less common
Fractures
6) present in __%
7. _____ and _____ most common
- 5-15% in all dislocations
- 40-50% in anterior/posterior dislocations
3a. fibrous tunnel at adductor hiatus
3b. fibrous tunnel at soleus muscle - common peroneal nerve injury (25%)
- tibial nerve
- 60%
- tibia and femur
Knee Dislocation - classification
Kennedy classification based on direction of displacement of the tibia (5 types)
anterior (30-50%)
◾most common
◾due to hyperextension injury
◾usually involves tear of PCL
◾arterial injury generally intimal tear due to traction
posterior (25%)
◾2nd most common
◾due to axial load to flexed knee (dashboard injury)
◾highest rate of vascular injury (25%) (direction of dislocation)
◾highest rate of complete tear of popliteal artery
lateral (13%)
◾due to varus or valgus force
◾usually involves tears of both ACL and PCL
◾highest rate of peroneal nerve injury
medial (3%)
◾varus or valgus force
◾usually disrupted PLC and PCL
rotational (4%)
◾posterolateral most common rotational dislocation
◾usually irreducible
◾buttonholding of femoral condyle through capsule
Knee Dislocation - Classification
Schenck Classification : based on pattern of multiligamentous injury of knee dislocation (KD)
Schenck Classification
◾KD I: Multilig injury with involvement of ACL or PCL
◾KD II Injury to ACL and PCL only (2 ligaments)
◾KD III Injury to ACL, PCL, and PMC or PLC (3 ligaments).
- KDIIIM (ACL, PCL, MCL) and - KDIIIL (ACL, PCL, PLC, LCL). * note: KDIIIM has highest rate of vascular injury (31%) based on Schenck classification
◾KD IV Injury to ACL, PCL, PMC, and PLC (4 ligaments)
◾KD V Multiligamentous injury with periarticular fracture
Knee Dislocation
Physical exam
- Appearance
a) no obvious deformity
b) obvious deformity - Stability
1 Appearance
a) no obvious deformity
◾50% spontaneously reduce before arrival to ED (therefore underdiagnosed)
◾may present with subtle signs of trauma (swelling, effusion, abrasions)
b) obvious deformity
◾reduce immediately, especially if absent pulses
◾”dimple sign” - buttonholing of medial femoral condyle through medial capsule
–> indicative of an irreducible posterolateral dislocation
–> ◾a contraindication to closed reduction due to risks of skin necrosis
- Diagnosis based on instability on exam (radiographs and gross appearance may be normal)
Knee Dislocation : Physical exam
- Vascular exam
NOTE: collateral circulation can mask a complete popliteal artery occlusion
- Action if ABI >0.9 ? (with pulses normal and present)
- Action if ABI <0.9 ? (with pulses normal and present)
- If pulses are absent or diminished:
a)
b)
c) ischemia time >8 hours= amputation risk up to ____%
d) if pulses present after reduction then measure ABI then consider ______ vs. ________
Vascular exam
◾priority is to rule out vascular injury on exam both before and after reduction
◾serial examinations are mandatory
◾palpate the dorsalis pedis and posterior tibial pulses
- monitor with serial examination (100% Negative Predictive Value)
- perform arterial duplex ultrasound or CT angiography
◾if arterial injury confirmed then consult vascular surgery - If pulses are absent or diminished
a) confirm that the knee joint is reduced or perform immediate reduction and reassessment
b) immediate surgical exploration if pulses are still absent following reduction
c) 86%
d) observation vs. angiography
https://www.vumedi.com/video/knee-clinical-examination-360-view-of-instability/
Knee Dislocation : Treatment
Initial Treatment
Nonoperative
- Reduce knee and re-examine vascular status
** considered an orthopedic emergency **
◾splint in 20-30° flexion
◾confirm reduction is held with repeat radiographs in brace/splint
◾vascular consult indicated if –> arterial injury confirmed by arterial duplex ultrasound or CT angiography OR pulses are absent or diminished following reduction - Nonoperative - indications
◾limited and most cases require surgical stabilization
Knee Dislocation : Treatment
- Emergent surgical intervention with external fixation
a) indications (6)
b) technique - Delayed ligamentous reconstruction/repair
a) indications
b) technique
1. Emergent surgical intervention with external fixation a) indications ◾vascular repair (takes precedence) ◾open fx and open dislocation ◾irreducible dislocation ◾compartment syndrome ◾obese ◾multi trauma patient
b) technique : vascular intervention
◾perform external fixation first
◾excision of damaged segment and repair with reverse saphenous vein graft
◾always perform fasciotomies after vascular repair
- Delayed ligamentous reconstruction/repair
a) indications
◾generally instability will require some kind of ligamentous repair or fixation
◾patients can be placed in a knee immobilizer for 6 weeks for initial stabilization
◾improved outcomes with early treatment (within 3 weeks)
b) technique
◾PLC : early reconstruction before ACL reconstruction
◾postoperative: recommend early mobilization and functional bracing
Knee Dislocation : Complications
- Most common complication ? ◦more common with delayed mobilization
- Laxity and instability ___%
- Peroneal nerve injury __%
◦most common in ______ dislocations
◦poor results with acute, subacute, and delayed (>3 months) nerve exploration
◦neurolysis and tendon transfers are the mainstay of treatment
◦Dynamic tendon transfer involves transferring the posterior tibial tendon (PTT) to the lateral cuneiform. - ______ compromise
- Stiffness / arthrofibrosis (38%): more common with delayed mobilization
- Laxity and instability (37%)
- Peroneal nerve injury (25%)
◦most common in posterolateral dislocations
◦poor results with acute, subacute, and delayed (>3 months) nerve exploration
◦neurolysis and tendon transfers are the mainstay of treatment
◦Dynamic tendon transfer involves transferring the posterior tibial tendon (PTT) to the lateral cuneiform. - Vascular compromise: in addition to vessel damage, claudication, skin changes, and muscle atrophy can occur
Proximal third tibia fractures
- High rates of malunion - malalignment ?
- Assoc with _____ compromise ?
- Incidence= __to__% of all tibial shaft fractures
- Mechanism
- Associated conditions (2)
- valgus AND apex anterior (procurvatum)
- soft tissue compromise
- 5-11%
- MOI:
◾low energy (result of torsional injury / indirect trauma)
◾high energy (direct trauma) - Associated conditions
◾compartment syndrome
◾soft tissue injury (critical to outcome)
Proximal third tibia fractures
Deforming forces
proximal fracture extended, apex anterior, varus
◾apex extended due to patellar tendon
◾varus due to pes anserinus + anterior compartment
distal fragment flexed
◾flexed due to hamstrings
Proximal third tibia fractures: Treatment of Closed Tibia Fractures
Nonoperative: closed reduction / cast immobilization
1. indications = closed low energy fractures with acceptable alignment (parameters) ◾< \_\_\_ degrees varus-valgus angulation ◾ \_\_\_% cortical apposition ◾< \_\_\_cm shortening ◾< \_\_\_ degrees rotational alignment
- technique
- outcome
1. acceptable alignment (parameters) ◾< 5 degrees varus-valgus angulation ◾< 10 degrees anterior/posterior angulation ◾> 50% cortical apposition ◾< 1 cm shortening ◾< 10 degrees rotational alignment
- technique
◾place in LL case; convert to functional brace at 4 weeks ◾cast in 10 to 20 degrees of flexion - Rotational control is difficult to achieve by closed methods
Proximal third tibia fractures : Operative
- External fixation
a) indications
b) technique - Intramedullary nailing
a) indications
b) outcomes
- External fixation
a) indications
◾fractures with extensive soft-tissue compromise
◾polytrauma
b) technique
◾bi-planar and multiplanar pin fixators are useful - Intramedullary nailing
a) indications
◾enough proximal bone to accept two locking screws (5-6 cm)
b) outcomes
◾high rates of malunion with improper technique ◾most common malunion = valgus AND procurvatum
Proximal third tibia fractures: Operative
- Percutaneous locking plate
a) indications
b) technique
c) outcomes
a) indications
◾inadequate proximal fixation for IM nailing
◾best suited for transverse or oblique fractures
◾minimal soft-tissue compromise
b) technique
◾may be used medially or laterally
◾better soft tissue coverage laterally makes lateral plating safer
c) outcomes
◾lateral plating with medial comminution can lead to varus collapse
◾long plates may place superficial peroneal nerve at risk
Proximal third tibia fractures : IMN
Surgical technique
- approach
- starting point
- approach
◾lateral parapatellar- helps maintain reduction for proximal 1/3 fractures
- requires mobile patella
- medial parapatellar may lead to valgus deformity
◾suprapatellar - facilitates nailing in semiextended position
- starting point
◾proximal to the anterior edge of the articular margin
◾just medial to the lateral tibial spine
◾use of a more lateral starting point may decrease valgus deformity
◾use of a medial starting point may create valgus deformity
Proximal third tibia fractures : IMN
Surgical technique
- Fracture reduction techniques
a) blocking (Poller) screws
b) unicortical plating
c) universal distractor
- Fracture reduction techniques
a) Blocking (Poller) screws
◾coronal blocking screw- prevents apex anterior (procurvatum) deformity
- place in posterior half of proximal fragment)
◾sagittal blocking screw - prevents valgus deformity
- place on lateral concave side of proximal fragment
◾enhance construct stability if not removed
b) unicortical plating
◾short one-third tubular plate placed anteriorly, anteromedially, or posteromedially across fracture
◾secure both proximally and distally with 2 unicortical screws
c) universal distractor
◾Schanz pins inserted from medial side, parallel to joint
◾pin may additionally be used as blocking screws
Proximal third tibia fractures : IMN
Surgical technique
- nail insertion : options (2)
- Locking screws
a) Static vs dynamic locking ?
b) number of screws?
- nail insertion options
a) standard insertion with knee in flexion
b) nail insertion in semiextended position
◾may help to prevent procurvatum deformity
◾neutralizes deforming forces of ext mechanism
- Locking screws
a) statically lock proximally and distally for rotational stability ◾no indication for dynamic locking acutely
b) must use at least two proximal locking screws
Proximal third tibia fractures
Complication: Malunion
- incidence = __to__% rate of malunion following intramedullary nailing (valgus/procurvatum)
- treatment
- Prevention (4)
- 20-60%
- Treatment
◾revision intramedullary nailing
OR
◾osteotomy if fracture has healed - Prevention
i. blocking screws
ii. temporary plating
iii. universal distractors
iv. nailing in semiextended position
Subtalar Dislocations
- Mechanism
- ___% open
- Medial vs lateral dislocations (%)
- Associated dislocations
- Associated fractures in up to ___%
- Fractures with medial dislocation (3)
- Fractures with lateral dislocation (4)
- Typically from a high-energy mechanism
- 25% may be open (lateral dislocations more likely to be open)
- 65% to 80% are medial; remaining are lateral
(note: case reports of anterior or posterior dislocations) - talonavicular
- 44%
- (i)dorsomedial talar head; (ii) posterior process of talus ; (iii) navicular
- (i) cuboid; (ii) anterior calcaneus; (iii) lateral process of talus; (iv) fibula
Subtalar Dislocation Presentation
- foot will be locked in ______ with medial dislocation
- foot will be locked in ______ with lateral dislocation
Imaging : Radiographs
Findings
3. medial dislocation
4. lateral dislocation
- supination
- pronation
- medial dislocation
◾talar head will be superior to navicular on lateral view - lateral dislocation
◾talar head will be collinear or inferior to navicular on lateral view
Subtalar Dislocations: Treatment
Nonoperative with closed reduction and short leg non-weight bearing cast for 4-6 weeks
- indications
- __to__% can be reduced by closed methods
- Technique maneuvers for reduction
- first line of treatment
- 60-70%
- Technique
◾requires adequate sedation
◾typical maneuvers include knee flexion and ankle plantar flexion
◾followed by distraction and hindfoot inversion or eversion depending on direction of dislocation
◾perform a post-reduction CT to look for associated injuries
Subtalar Dislocations: Treatment
Operative: ie. open reduction
- indications
- Up to ___% require open reduction
- medial dislocation reduction blocked by: (3)
- lateral dislocation reduction blocked by: (3)
- If unstable post reduction ?
- failure of closed reduction
- 32%
- medial dislocation reduction blocked by
◾ peroneal tendons
◾extensor digitorum brevis
◾talonavicular joint capsule - lateral dislocation reduction blocked by:
◾PTT is the most common
◾ FHL
◾ FDL - Place temporary transarticular pins as needed
Subtalar Dislocations : Complications
Post-traumatic Arthritis
◾ Long-term follow up of these injuries show degenerative changes
◾Subtalar joint most commonly affected
◾Up to 89% of have radiographic arthrosis
◾Up to 63% of have symptomatic arthrosis
Talus Fracture (other than neck)
Epidemiology
- Less than __% of all fractures
- ______ most common tarsal fractures after calcaneus fxs
- talar body fractures: account for __to__% of talus fractures
- lateral process fractures: account for ___% of talus fractures
- Talar head fracture: _____common talus fracture
- less than 1%
- second
- 13-23% of talus fractures
- 10.4% of talus fractures
- LEAST common talus fracture
Talus Fracture (other than neck)
Mechanism
1. talar body
- lateral process of talus
- Prognosis
- talar body
◾injuries often result from high energy trauma, with the hindfoot either in supination or pronation - lateral process of talus
◾injuries result from forced dorsiflexion, axial loading, and inversion with external rotation
◾often seen in snowboarders - Prognosis
◾ lateral process injuries have a favorable outcomes with prompt diagnosis and immediate treatment
Talus Fracture (other than neck) : Anatomy 1. Number of muscular and tendinous attachments
- There are ___ articulating surfaces
- ____% of talus is covered by cartilage
- inferior surface articulates with ________
- talar head articulates with: (2)
- lateral process articulates with: (2)
- posterior process consist of medial and lateral tubercle separated _______
- Zero
- 5 articulating surfaces
- 70%
- Posterior facet of calcaneus
- i) navicular bone; ii) sustenaculum tali
- i) posterior facet of calcaneus; ii) lateral malleolus of fibula (this forms the lateral margin of the talofibular joint)
- groove for FHL
Talus Fracture (other than neck): Anatomy
Blood supply : because of limited soft tissue attachments, the talus has a direct extra-osseous blood supply
Sources include (4)
- Posterior tibial artery
◾via artery of tarsal canal (most important and main supply) –> supplies most of talar body
◾via calcaneal braches –> supplies posterior talus - Anterior tibial artery
◾supplies head and neck - Perforating peroneal arteries via artery of tarsal sinus –> supplies head and neck
- Deltoid artery (located in deep segment of deltoid ligament)
◾supplies body
◾may be only remaining blood supply with a talar neck fracture
Talus Fracture (other than neck)
Anatomic classification
- Lateral Process Fx (2 types)
Lateral Process Fx
◾type 1 fractures do not involved the articular surface
◾type 2 fractures involve the subtalar and talofibular joints
◾type 3 fractures have comminution
◦Posterior Process Fx
◾posteromedial tubercle fractures ◾result from an avulsion of the posterior talotibial ligament or posterior deltoid ligament
◾posterolateral tubercle fractures ◾result from an avulsion of the posterior talofibular ligament
◦Talar Head Fx
◦Talar Body Fx
Talus Fracture (other than neck)
Anatomic classification
i. Posterior Process Fx (2 types)
Others
ii. Talar head fx
iii. Talar body fx
- Posteromedial tubercle fractures
◾result from an avulsion of the posterior talotibial ligament or posterior deltoid ligament - posterolateral tubercle fractures
◾result from an avulsion of the posterior talofibular ligament
Talus Fracture (other than neck)
Imaging
- What is Canale view
Canale View: optimal view of talar neck
◾technique
◾maximum equinus
◾15% pronated
◾Xray 75 degrees cephalad from horizontal
NB:
◾careful not to mistake os trigonum (present in up to 50%) for fracture
◾may be falsely negative in talar lateral process fx
Talus Fracture (other than neck)
Treatment : Nonoperative with SLC for 6 weeks
- indications
Treatment : Operative
2. Options
- Indications
◾nondisplaced (< 2mm) lateral process fractures
◾nondisplaced (< 2mm) posterior process fractures
◾nondisplaced (< 2mm) talar head fractures
◾nondisplaced (< 2mm) talar body fractures
Talus Fracture (other than neck)
Treatment : Operative
- ORIF/Kirshner wire Fixation
◾indications ◾displaced (> 2mm) lateral process fractures
◾displaced (> 2mm) talar head fractures
◾displaced (> 2mm) talar body fractures
- medial, lateral or posterior malleolar osteotomies may be necessary
◾displaced (> 2mm) posteromedial process fractures
- may require osteotomies of posterior or medial malleoli to adequately reduce the fragments - fragment excision : indications
◾comminuted lateral process fractures
◾comminuted posterior process fractures
◾nonunions of posterior process fractures
Talus Fracture (other than neck)
- Complications (5)
- What does Hawkins indicate?
- Rate of ST arthritis after lateral process fractures, treated either non-operatively or operatively ?
- Complications
i. AVN
ii. Talonavicular arthritis (PTOA is common in all of these fractures; this can be treated with an arthrodesis of the talonavicular joint)
iii. Malunion
iv. Chronic pain from symptomatic nonunion (may have pain up to 2 years after treatment)
v. Subtalar arthritis - hawkins sign
◾subchondral lucency best seen on mortise Xray at 6-8 weeks ◾indicates intact vascularity with resorption of subchondral bone - 45%
Talus Fracture (other than neck)
Surgical Technique
ORIF/Kirshner Wires
- approaches (4)
Approaches
- lateral approach
◾for lateral process fractures
◾incision over tarsal sinus, reflect EDB distally - posteromedial approach
◾for medial tubercle of posterior process fracture or for entire posterior process fracture that has displaced medially
◾between FDL and neurovascular bundle - posterolateral approach
◾for lateral tubercle of posterior process fractures
◾between peroneal tendons and Achilles tendon (protect sural nerve)
◾beware when dissecting medial to FHL tendon (neurovascular bundle lies there) - combined lateral and medial approach
◾required for talar body fractures with more than 2 mm of displacement
Talar Neck Fractures
- incidence
- mechanism
- associated conditions
- most common fracture of talus ( 50%)
- MOI
◾ a high-energy injury
◾ is forced dorsiflexion with axial load - ipsilateral lower extremity fractures common
Talar Neck Fractures
Classification
1. Eponymous name
◾ details and % risk of AVN (4 types)
- Hawkins Classification
◾ Hawkins I: Nondisplaced (0-13% AVN)
◾ Hawkins II: Subtalar dislocation (AVN risk 20-50%)
◾ Hawkins III: Subtalar and tibiotalar dislocation (AVN risk 20-100%)
◾ Hawkins IV: Subtalar, tibiotalar, and talonavicular dislocation (AVN risk 70-100%)
Talar Neck Fractures: Treatment
- Initial treatment = emergent reduction in ER
◾indications - Nonoperativeshort leg cast for 8-12 weeks (NWB for first 6 weeks)
◾indications - Operative ◦open reduction and internal fixation
a) indications
b) techniques
c) complications
- initial Rx: emergent reduction in ER
◾all cases require emergent closed reduction in ER - Short leg cast for 8-12 weeks (NWB for first 6 weeks) Indications
◾nondisplaced fractures (Hawkins I)
◾CT to confirm nondisplaced without articular stepoff
3 Operative (ORIF) :
a) indications
◾all displaced fractures (Hawkins II-IV)
b) techniques
◾extruded talus should be replaced and treated with ORIF
c) complications
◾post-traumatic arthritis
◾mal-union
◾non-union
◾infection
◾wound dehiscence
Talar Neck Fractures Surgical Techniques
ORIF
- Approach
- Technique
- Postoperative
- Approach
◾two approaches recommended
- visualize medial and lateral neck to assess reduction
- typical areas of comminution are dorsal and medial
◾anteromedial- between tibialis ant and posterior tib
- preserve soft tissue attachments, especially deep deltoid ligament (blood supply)
- medial malleolar osteotomy to preserve deltoid ligament
◾ anterolateral - between tibia and fib proximally, in line with 4th ray
- elevate extensor digitorum brevis and remove debris from subtalar joint
Talar Neck Fractures Surgical Techniques
ORIF
- Technique
- Postoperative
- Technique
◾anatomic reduction essential
◾variety of implants used including mini and small fragment screws, cannulated screws and mini fragment plates
◾medial and lateral lag screws may be used in simple fracture patterns
◾consider mini fragment plates in comminuted fractures to buttress against varus collapse - Postoperative
◾non-weight-bearing for 10-12 weeks
- NB: timing of surgery NOT as important as anatomical reduciton for reducing rates of AVN *
Talar Neck Fractures : Complications
- Osteonecrosis = __% overall (including all subtypes)
- PTOA
a) ______ arthritis (__%) is the most common complications
b) tibiotalar arthritis __%) - Varus malunion __to__%
◦treatment includes medial opening wedge osteotomy of talar neck - Varus malunion leads to: (2)
- 31%
2a) Subtalar arthritis (50%)
2b) 33% - Varus malunion 25-30%
- Varus malunion leads to
i) decreased subtalar eversion (decreased motion with locked midfoot and hindfoot)
ii) weight bearing on the lateral border of the foot
Tibial Plateau Fractures
Definitions: Periarticular injuries of the proximal tibia frequently associated with soft tissue injuries
- Epidemiology (distribution/age/gender)
- Location
- Epidemiology
◾bimodal distribution
◾males in 40s (high-energy trauma)
◾females in 70s (falls) - Location
◾unicondylar vs. bicondylar
◾frequency = lateral > bicondylar > medial
Tibial Plateau Fractures
Mechanism
◦varus/valgus load with or without axial load
◦high energy
◾frequently associated with soft tissue injuries
◦low energy
◾usually insufficiency fractures
Tibial Plateau Fractures
Associated conditions (4)
- meniscal tears
i) lateral meniscal tear
◾more common than medial
◾associated with Schatzker II fracture pattern
◾associated with >10mm articular depression
ii) medial meniscal tear
◾most commonly assoc with Schatzker IV fractures - ACL injuries
◾more common in type IV and VI fractures (25%) - Compartment syndrome
- Vascular injury
◾commonly associated with Schatzker IV fracture-dislocations
Tibial Plateau Fractures
- Anatomy
- Biomechanics
- Anatomy
a) Osteology lateral tibial plateau
◾convex in shape
◾proximal to the medial plateau
b) Osteology medical tibial plateau
◾concave in shape
◾distal to the lateral tibial plateau
c) Muscles : anterior compartment musculature ◾attaches to anterolateral tibia
d) Muscles :pes anserine
◾attaches to anteromedial tibia
- Biomechanics
◦medial tibial plateau bears 60% of knee’s load
Tibial Plateau Fractures
Classification
Schatzker Classification
Type I Lateral split fracture
Type II Lateral Split-depressed fracture
Type III Lateral Pure depression fracture
Type IV Medial plateau fracture
Type V Bicondylar fracture
Type VI Metaphyseal-diaphyseal disassociation
Tibial Plateau Fractures
Presentation
◾look circumferentially to rule-out an open injury
◾consider compartment syndrome when compartments are firm and not compressible
◾varus/valgus stress testing –> any laxity >10 degrees indicates instability
◾neurovascular exam –> any differences in pulse exam between extremities should be further investigated with anke-brachial index measurement
Tibial Plateau Fractures
Imaging
CT and MRI
CT scan = important to identify articular depression and comminution
Findings
◾lipohemarthrosis indicates an occult fracture
◾fracture fragment orientation and surgical planning
MRI
◦indications ◾not well established
◦findings ◾useful to determine meniscal and ligamentous pathology
Tibial Plateau Fractures
Treatment : Nonoperative
Treatment: Nonoperative
Hinged knee brace, PWB for 8-12 weeks, and immediate passive ROM
Indications
◾minimally displaced split or depressed fractures
◾low energy fracture stable to varus/valgus alignment
◾nonambulatory patients
Tibial Plateau Fractures Operative
- temporizing bridging external fixation w/ delayed ORIF ◾indications ?
- External fixation with limited open/percutaneous fixation of articular segment
◾indications ?
◾outcomes
- temporizing bridging external fixation w/ delayed ORIF
◾indications = significant soft tissue injury ; polytrauma - External fixation with limited open/percutaneous fixation of articular segment
◾indications = severe open fracture with marked contamination ; highly comminuted fractures where internal fixation not possible
◾outcomes = similar to open reduction, internal fixation
Tibial Plateau Fractures
ORIF
a) indications (5)
Indications ◾articular stepoff > 3mm ◾condylar widening > 5mm ◾varus/valgus instability ◾all medial plateau fxs ◾all bicondylar fxs
Tibial Plateau Fractures
ORIF
Outcomes
Outcomes
◾restoration of joint stability is strongest predictor of long-term outcomes
◾postoperative infection after ORIF associated with
- male gender
- smoking
- pulmonary disease
- bicondylar fracture pattern
- intraoperative time over 3 hours
◾timing of definitive fixation (before, during or after) relative to fasciotomy closure does not increase the risk of infection
◾worse results with
- ligamentous instability
- meniscectomy
- alteration of limb mechanical axis > 5 degrees
Tibial Plateau Fractures
Techniques : External fixation (temporary)
a) technique
b) advantages
a) technique
◾two 5-mm half-pins in distal femur, two in distal tibia
◾axial traction applied to fixator
◾fixator is locked in slight flexion
b) advantages
◾allows soft tissue swelling to decrease before definitive fixation
◾decreases rate of infection and wound healing complications
Tibial Plateau Fractures
Techniques : External fixation with limited internal fixation (definitive)
a) technique
b) post-op
c) pros
d) cons
a) technique
◾reduce articular surface either percutaneously or with small incisions
◾stabilize reduction with lag screws or wires (must keep wires >14mm from joint)
◾apply external fixator or hybrid ring fixation
b) post-operative care
◾begin weight bearing when callus is visible on radiographs
◾usually remain in place 2-4 months
c) pros
◾minimizes soft tissue insult
◾permits knee ROM
d) cons
◾pin site complications
Tibial Plateau Fractures
Techniques : ORIF
Approach (5)
a) Approach
1. lateral incision (most common)
◾straight or hockey stick incision anterolaterally from just proximal to joint line to just lateral to the tibial tubercle
- midline incision (if planning TKA in future)
◾can lead to significant soft tissue stripping and should be avoided - Posteromedial incision
◾interval between pes anserinus and medial head of gastrocnemius - Dual surgical incisions with dual plate fixation
◾indications= bicondylar tibial plateau fractures - Posterior
◾can be used for posterior shearing fractures
Tibial Plateau Fractures
Techniques : ORIF
Reduction
◾restore joint surface with direct or indirect reduction
◾fill metaphyseal void with autogenous, allogenic bone graft, or bone graft substitutes
- calcium phosphate cement has high compressive strength for filling metaphyseal void
Tibial Plateau Fractures
Techniques : ORIF
Internal fixation
a) absolute or relative
b) screws
c) plate fixation
a) absolute stability constructs should be used to maintain the joint reduction
b) screws may be used alone for:
- simple split fractures
- depression fractures that were elevated percutaneously
c) plate fixation
i. non-locked plates
◾non-locked buttress plates best indicated for simple partial articular fractures in healthy bone
ii. locked plates
◾advantages
◾fixed-angle construct
◾less compression of periosteum and soft tissue
Tibial Plateau Fractures
Techniques : ORIF
postoperative
postoperative
◾hinged knee brace with early passive ROM
- gentle mechanical compression on repaired osteoarticular segments improves chondrocyte survival
◾NWB or PWB for 8 to 12 weeks
Tibial Plateau Fractures
Complications : Post-traumatic arthritis
Rate increases with (4)
- meniscectomy during surgery
- axial malalignment
- intra-articular infection
- joint instability
Tibial Plafond Fractures
Epidemiology
◦incidence
◦demographics [age/gender]
incidence
◾account for <10% of lower extremity injuries
◾incidence increasing as survival rates after motor vehicle collisions increase
◦demographics
◾average patient age is 35-40 years
◾more common in males than females
Tibial Plafond Fractures : Pathophysiology
- mechanism
- pathoanatomy : often characterized by (4)
- Three fragments typical with intact ankle ligaments
- high energy axial load (motor vehicle accidents, falls from height)
2. Often characterized by: ◾articular impaction and comminution ◾metaphyseal bone comminution ◾soft tissue injury (open or Tscherne II/III closed fractures) ◾associated musculoskeletal injuries
- Fragments typical with intact ankle ligaments:
i. medial malleolar (deltoid ligament)
ii. posterolateral/Volkmann fragment (posterior inferior tibiofibular ligament)
iii. anterolateral/Chaput fragment (anterior inferior tibiofibular ligament)
Tibial Plafond Fractures
1Assoc conditions = ___% have assoc fibula fractures
- Prognosis: parameters that correlate with a poor clinical outcome and inability to return to work (5)
- 75%
2.Parameters that correlate with a poor clinical outcome and inability to return to work ◾lower level of education ◾pre-existing medical comorbidities ◾male sex ◾work-related injuries ◾lower income levels
Tibial Plafond Fractures
Imaging
4 characterisic fragments
4 characterisic fragments ◾medial malleolus ◾anterior malleolus = chaput ◾lateral malleolus = wagstaffe ◾posterior malleolus = volkmann
Tibial Plafond Fractures: Treatment
- Nonoperative: indications
- Outcomes
- indications
◾stable fracture patterns without articular surface displacement
◾critically ill or nonambulatory patients
◾significant risk of skin problems (diabetes, vascular disease, neuropathy) - Outcomes
◾intra-articular fragments are unlikely to reduce with manipulation of displaced fractures
◾loss of reduction is common
◾inability to monitor soft tissue injuries is a major disadvantage
Tibial Plafond Fractures : Operative
- temporizing spanning external fixation across ankle joint
◾indications
2 ORIF
◾indications
◾outcomes
1: indications (Ex-Fix)
◾acute management (provides stabilization to allow for soft tissue healing)
◾fractures with significant joint depression or displacement
◾leave until swelling resolves (generally 10-14 days)
2a. Indications (ORIF)
◾definitive fixation for majority of pilon fractures
◾limited or definitive ORIF can be performed acutely with low complications in certain situations
2b.Outcomes
◾ability to drive (brake travel time returns to normal 6 weeks after weight bearing)
Tibial Plafond Fractures
- External fixation alone
◾indications
4 IMN with percutaneous screw fixation
◾indications
◾alternative to ORIF for fractures with simple intra-articular component (AO/OTA 43 C1/C2)
- external fixation alone
◾indications = may be indicated in select cases - IMN with percutaneous screw fixation
◾alternative to ORIF for fractures with simple intra-articular component (AO/OTA 43 C1/C2)
Tibial Plafond Fractures: Techniques
External fixation
- joint-spanning articulated vs. nonspanning hybrid ring ?
- __ tibial shaft half pins connected to hindfoot half pins or calcaneal transfixation pin
- soft tissues
- Pros
- Cons
- none have been shown to be superior with respect to ankle stiffness
- 2
(with hybrid fixators, thin wires may be placed within joint capsule or within zone of injury - soft tissues
◾maintain soft tissue attachments of fragments ◾Chaput fragment - anterior inferior tibiofibular ligament - pros
◾decreased incidence of wound complications and deep infections compared to ORIF
◾can combine with limited percutaneous fixation using lag screws
5. Cons ◾pin and wire tract infections ◾loss of ankle motion ◾injury to neurovascular structures ◾anatomic articular reconstruction may not be possible, especially with central depression
Tibial Plafond Fractures: Techniques
ORIF
Goals (5)
◾anatomic reduction of articular surface ◾restore length ◾reconstruct metaphyseal shell ◾bone graft ◾reattach metaphysis to diaphysis
Tibial Plafond Fractures: Techniques
ORIF
Approach
1. use of multiple small incisions that can include: (7)
- ___ cm skin bridge and ____________ skin flaps)
Use of multiple small incisions that can include
i. direct anterior approach to ankle
ii. anterolateral approach to ankle
◾useful with fractures impacted in valgus or with an intact fibula
◾puts the deep peroneal nerve at risk during exposure and dissection in the anterior compartment
◾superficial peroneal nerve at risk during superficial dissection in the lateral compartment
iii. anteromedial approach to ankle
iv. medial approach
v. posteromedial approach
vi. posterolateral approach
vii. lateral approach
- Generally >7 cm skin bridge; full thickness skin flaps
Tibial Plafond Fractures: Techniques
ORIF
- Steps
- Fixation
- Steps
◾reduce and instrument fibula to establish lateral column length (if needed)
◾when compared to no instrumentation of the fibula no difference in alignment or reduction but higher rates of fibular hardware removal
◾reduce articular surface
◾reattach articular block to metaphysis and shaft - Fixation
◾may be augmented with external fixation (with or without limited ORIF)
◾can use anterolateral, anterior, anteromedial, medial, or posterior plating techniques for the tibia (location of plates/screws are fracture and soft-tissue dependent)
◾ORIF of fibula if needed (can be with intramedullary screw/wire or plate/screw construct)
Tibial Plafond Fractures: Techniques
ORIF
- pros
- cons
1. pros ◾direct anatomic reduction ◾rigid fixation ◾early motion of ankle ◾clinical improvement may occur for up to 2 years
- cons
◾high incidence of soft tissue complications and infection without staged ORIF
Tibial Plafond Fractures: Complications
- Wound slough = ___%
- Dehiscence =__to__%
- Infection = __to__%
- Others (5)
- 10% (free flap for postoperative wound breakdown)
- 9-30% (◦wait for soft tissue edema to subside before ORIF -> 1-2 weeks)
- 5-15%
- Other
i.Varus malunion
ii. Nonunion
◦usually at metaphyseal junction
◦treat with bone grafting and plate fixation
◦more common with hybrid fixation
iii. Posttraumatic arthritis
◦most commonly begins 1-2 years postinjury
◦arthrodesis is not commonly required until many years later
◦chondrocyte cell death at fracture margins is a contributing factor
iv. Chondrolysis
v. Stiffness
Femoral Neck Fractures
- Epidemiology
a. incidence
b. gender
c. race (USA)
d. cost - Mechanism (2)
- Epidemiology
a. increasingly common due to aging population
b. women > men
c. whites > blacks (United states has highest incidence of hip fx rates worldwide)
d. most expensive fracture to treat on per-person basis - MOI
◦high energy in young patients
◦low energy falls in older patients
Femoral Neck Fractures
- Associated injuries (1)
- Pathophysiology: healing potential
- Femoral shaft fractures
◾6-9% associated with femoral neck fractures
◾treat femoral neck first followed by shaft - Healing potential
◾femoral neck is intracapsular, bathed in synovial fluid
◾lacks periosteal layer
◾callus formation limited, which affects healing
Femoral Neck Fractures
Prognosis
1. mortality = __to__ at one year
- predictors of mortality (2)
- 25-30% at one year (higher than vertebral compression fractures)
- predictors of mortality
◾pre-injury mobility is the most significant determinant for post-operative survival
◾in patients with chronic renal failure, rates of mortality at 2 years postoperatively, are close to 45%
Femoral Neck Fractures
Anatomy
1. normal neck shaft-angle ___+/-___degrees
2. normal anteversion ___+/-___degrees
Blood Supply
3. major contributor is _______ artery
4. some contribution to anterior and inferior head from _________
5. some contribution from ______ artery
6. small and insignificant supply from artery of __________
- 130 +/- 7 degrees
- 10 +/- 7 degrees
Blood supply to femoral head
- medial femoral circumflex (lateral epiphyseal artery)
- lateral femoral circumflex
- inferior gluteal artery
- artery of ligamentum teres
note: displacement of femoral neck fracture will disrupt the blood supply and cause an intracapsular hematoma (effect is controversial)
Femoral Neck Fractures
- Classification
- Types
- Garden Classification
(based on AP radiographs and does not consider lateral or sagittal plane alignment) - Types
Type I Incomplete, ie. valgus impacted
Type II Complete fx. nondisplaced
Type III Complete, partially displaced
Type IV Complete, fully displaced
** note: Posterior roll-off and/or angulation of femoral head leads to increased reoperation rates
Femoral Neck Fractures : Treatment
Operative Indications
- ORIF
- Cannulated screw fixation
- Sliding hip screw
- Hemiarthroplasty
- Total hip arthoplasty
- ORIF: indications
◾displaced fractures in young or physiologically young patients (ORIF indicated for most pts <65 yo) - Cannulated screw fixation: indications ◾nondisplaced transcervical fx
◾Garden I or II in the physiologically elderly
◾displaced transcervical fx in young patient- considered a surgical emergency
- achieve reduction to limit vascular insult
- reduction must be anatomic, so open if necessary
- Sliding hip screw: indications
◾basicervical fracture
◾vertical fracture pattern in a young patient- biomechanically superior to cannulated screws
◾consider placement of additional cannulated screw above sliding hip screw to prevent rotation
- biomechanically superior to cannulated screws
- hemiarthroplasty: indications
◾controversial
◾debilitated elderly patients
◾metabolic bone disease - Total hip arthoplasty : indications
◾controversial
◾older active patients
◾patients with preexisting hip osteoarthritis
- more predictable pain relief and better functional outcome than hemiarthroplasty
◾Garden III or IV in patient < 85 years
Femoral Neck Fractures
General Surgical Consideration
- Time to surgery ◾controversial ◾reduction method and quality has more pronounced effect on healing than surgical timing
- Time to surgery
◾controversial as reduction method and quality has more pronounced effect on healing than surgical timing
◾elderly patients with hip fractures should be brought to surgery as soon as medically optimal
–> the benefits of early mobilization cannot be overemphasized
–> improved outcomes in medically fit patients if surgically treated less than 4 days from injury
Femoral Neck Fractures
General Surgical Consideration
Treatment approach based on (3)
Treatment approach based on
- degree of displacement
- physiologic age of the patient (young is < than 50
- ipsilateral femoral neck and shaft fractures
◾priority goes to fixing femoral neck because anatomic reduction is necessary to avoid complications of AVN and nonunion
Femoral Neck Fractures
General Surgical Consideration
Fixation with implants that allow sliding
- Permit _______
- Can cause shortening of femoral neck leading to: (4)
- __________with intraop compression and placement of _________ stable devices decrease shortening
Fixation with implants that allow sliding
- permit dynamic compression at fx site during axial loading
2. Can cause shortening of femoral neck ◾prominent implants ◾affects biomechanics of hip joint ◾lower physical function on SF-36 ◾decreased quality of life
- ANATOMIC REDUCTION with intraop compression and placement of LENGTH stable devices decrease shortening
Femoral Neck Fractures
Open versus closed reduction
- Worse outcomes with displacement > ____mm
- Which is superior ?
- Multiple closed reduction attempts are associated with _________________?
Open versus closed reduction ◾
- > 5 mm (higher rate of osteonecrosis and nonunions)
- No consensus on which reduction approach is superior
- Higher risk of osteonecrosis of the femoral head
Femoral Neck Fractures
Cannulated Screw Fixation : Technique
Cannulated Screw Fixation
◾three screws if noncomminuted (3 screw inverted triangle shown to be superior to two screws)
◾order of screw placement (this varies)
i. 1-inferior screw along calcar
ii. 2-posterior/superior screw
iii. 3-anterior/superior screw
◾obtain as much screw spread as possible in femoral neck [inverted triangle along the calcar (not central in the neck) has stronger fixation and higher load to failure]
◾four screws considered for posterior comminution
–> clear advantage of additional screws not proven in literature
◾starting point at or above level of lesser trochanter to avoid fracture
◾avoid multiple cortical perforations during guide pin or screw placement to avoid development of lateral stress riser
Femoral Neck Fractures
Hemiarthroplasty: Technique
approach ?
Cemented or uncemented ?
◾posterior approach has increased risk of dislocations
◾anterolateral approach has increased abductor weakness
◾cemented superior to uncemented
◾unipolar vs. bipolar
Femoral Neck Fractures
THA: Technique
- Head size ?
- Pros
- Complications
- Should consider using the anterolateral approach and selective use of larger heads in the setting of a femoral neck fracture
- Advantages
◾improved functional hip scores and lower re-operation rates compared to hemiarthroplasty - Complications
◾higher rate of dislocation with THA (~ 10%)
◾about five times higher than hemiarthroplasty
Femoral Neck Fractures : Complications
Osteonecrosis
- incidence
- association between time to fracture reduction and subsequent AVN ?
- increased risk with: (2)
- Treatment
- incidence of 10-45% q q
- recent studies fail to demonstrate association between time to fracture reduction and subsequent AVN
- increased risk with:
i. increase initial displacement (◾AVN can still develop in nondisplaced injuries)
ii. nonanatomical reduction - Treatment (note: major symptoms not always present when AVN develops)
a) young patient
◾> 50% involvement then treat with free-vascularised-fibula-graft (FVFG) vs THA
b) older patient
◾prosthetic replacement (hemiarthroplasty vs THA)
Femoral Neck Fractures : Complications
Nonunion
- incidence
- increased incidence in __(a)__. NO correlation between _(b)__, __(c)__, and rate of nonunion
- ______ malreduction most closely correlates with failure of fixation with canny screws
- Treatment (3)
- 5 to 30%
2a. displaced fractures
2b. age
2c. gender
- VARUS malreduction most closely correlates with failure of fixation after reduction and cannulated screw fixation.
4.Treatement
i) valgus intertrochanteric osteotomy
◾indicated in patients after femoral neck nonunion
ii) free vascularized fibula graft (FVFG)
◾indicated in young pt with a nonviable femoral head
iii) arthroplasty
◾indicated in older patients or when the femoral head is not viable
◾also an option in younger patient with a nonviable femoral head as opposed to FVFG
iv) revision ORIF
Femoral Neck Fractures : Complications
Dislocation
1. Rate of dislocation with THA (in NOF#)
Failure rates = high early failure rates in fixation group, which stabilizes after 2 years
- Two-year follow-up (elderly population >70 years) with displaced femoral neck fractures
a) ____% with fixation techniques
b) ____% with arthroplasty techniques - Two-to-ten follow-up failure rate approx.
a) ___% (fixation)
b) ___% (arthroplasty) - Overall failure rates still _______ in fixation vs. arthoplasty at 10-year follow-up
- ~ 10%
2a. 46%
2b. 8%
3a. 2%
3b. 4% - Higher
Intertrochanteric Fractures
- incidence compared to femoral neck fractures
- female:male ratio
- Age
- Risk factors (1)
- Pathophysiology: mechanism (2 groups)
- roughly the same as femoral neck fractures
- female:male ratio between 2:1 and 8:1
3 ypically older age than patients with femoral neck fractures
- risk factors ◾proximal humerus fractures increase risk of hip fracture for 1 year
5. Pathophysiology ◦mechanism
◾elderly
-low energy falls in osteoporotic patients
◾young
- high energy trauma
Intertrochanteric Fractures
Prognosis
- nonunion and malunion rates are _____?
- __to__% mortality risk in the 1st year
- Factors that increase mortality (6)
- Surgery within ___hours decreases 1 year mortality
- low
- 20-30%
- Increase mortality
a) male (25-30% mortality) vs female (20% mortality)
b) higher in intertroch fracture (vs femoral neck fx)
c) operative delay of >2 days
d) age >85 years
e) 2 or more pre-existing medical conditions
f) ASA class. (ASA III and IV increases mortality) - 48 hours
** NB: early medical optimization and co-management with medical hospitalists or geriatricians can improve outcomes
Intertrochanteric Fractures
Antomy
Q. What is the calcar femorale
Calcar femorale
◾vertical wall of dense bone that extends from posteromedial aspect of femoral shaft to posterior portion of femoral neck
◾helps determine stable versus unstable fracture patterns
Intertrochanteric Fractures
Classification
Stability of fracture pattern is arguably the most reliable method of classification
- Stable
a) definition
b) clinical significance - Unstable
a) definition
b) clinical significance
c) examples
- Stable
a) definition
◾intact posteromedial cortex
b) clinical significance
◾will resist medial compressive loads once reduced - Unstable
a) definition
◾comminution of the posteromedial cortex
b) clinical significance
◾fracture will collapse into varus and retroversion when loaded
c) examples
i) fractures with a large posteromedial fragment (i.e., lesser trochanter is displaced)
ii) subtrochanteric extension
iii) reverse obliquity (oblique fracture line extending from medial cortex both laterally and distally)
Intertrochanteric Fractures: Treatment
Operative
- Sliding hip compression screw
a) indications
b) outcomes - Intramedullary hip screw (cephalomedullary nail)
a) indications
b) outcomes - Reverse obliquity fractures have a ___% failure when treated with sliding hip screw
◾Lack of integrity of femoral wall associated with increased displacement and collapse when treated with ____________
- Sliding hip compression screw
a) indications = stable intertrochanteric fractures
b) outcomes = equal outcomes when compared to intramedullary hip screws for STABLE fracture patterns - Intramedullary hip screw (cephalomedullary nail)
a) indications
◾stable AND unstable fracture patterns
◾lack of integrity of femoral wall
b) outcomes
◾equivalent to sliding hip screw for stable fxs
◾use has significantly increased in last decade - 56%
- Sliding hip screw
Intertrochanteric Fractures
Techniques : Sliding hip compression screw
- must obtain _______
- lag screw with tip-apex distance >___ mm is associated with increased failure rates
- 4 hole OR 2 hole plates ?
- Pros (3)
- Cons (3)
- correct neck-shaft relationship
- > 25 mm
- 4-hole plates show no benefit clinically or biomechanically over 2-hole plates
- Pros
◾allows dynamic interfragmentary compression
◾low cost
◾no violation of hip abductors - Cons
◾open technique
◾increased blood loss
◾ in unstable # patterns may result in:
- collapse
- limb shortening
- medialization of shaft
Note: can cause anterior spike malreduction in left-sided, unstable fractures due to screw torque
Intertrochanteric Fractures
Intramedullary hip screw
Technique 1. short implants with optional distal locking ◾indicaitons (1) 2. long implants ◾indicaitons (3) 3. Pros (3) 4. Cons (3)
- short implnats : standard obliquity fractures
- long implants
◾standard obliquity fractures
◾reverse obliquity fractures
◾subtrochanteric extension - Pros
◾percutaneous approach
◾minimal blood loss
◾may be used in unstable fracture patterns - Cons
◾periprosthetic fracture
◾higher cost than sliding hip screw
◾requires violation of hip abductors for insertion
Intertrochanteric Fractures
Arthroplasty : Technique
- ________ prosthesis often needed
- must attempt fixation of ___________ to shaft
- Pros (1)
- Cons (2)
- Calcar-replacing
- Must attempt fixation of greater trochanter to shaft
- Pros
◾possible earlier return for full weight bearing - Cons
◾increased blood loss
◾may require prosthesis some surgeons are unfamiliar with
Intertrochanteric Fractures
Complications
- Implant failure and cutout
a) incidence
b) cause
c) treatment
◾young
◾elderly
- Implant failure and cutout
a) incidence
◾most common complication
◾usually occurs within first 3 months
b) cause
◾tip-apex distance >45 mm associated with 60% failure rate
c) treatment
◾young = corrective osteotomy and/or revision open reduction and internal fixation
◾elderly = total hip arthroplasty
Intertrochanteric Fractures
Complications
- Anterior perforation of the distal femur
a) incidence
b) cause - Nonunion
a) incidence
b) treatment - Malunion
a) incidence
b) treatment
- Anterior perforation of the distal femur
a) incidence : ◾can occur following intramedullary screw fixation
b) cause: ◾mismatch of the radius of curvature of the femur (shorter) and implant (longer)
2 Nonunion
a) incidence = ◾<2%
b) Treatment
◾revision ORIF with bone grafting
◾proximal femoral replacement
- Malunion
a) incidence: ◾varus and rotational deformities are common
b) treatment: ◾corrective osteotomies
Subtrochanteric Fractures
Subtrochanteric typically defined as:
Subtrochanteric typically defined as area from lesser trochanter to 5cm distal
Fractures with an associated intertrochanteric component may be called
◾intertrochanteric fracture with subtrochanteric extension
◾peritrochanteric fracture
Subtrochanteric Fractures
Epidemiology
- age
- mechanism
- associated with
- usually in younger patients with a high-energy mechanism
- may occur in elderly patients from a low-energy mechanism
- Rule out pathologic or atypical femur fracture ◾denosumab or bisphosphonate use, particularly alendronate, can be risk factor
Subtrochanteric Fractures
Pathoanatomy
- deforming forces on the proximal fragment
- deforming forces on distal fragment
deforming forces on the proximal fragment are:
1. abduction
◾gluteus medius and gluteus minimus
2. flexion
◾iliopsoas
3. External rotation
◾short external rotators
deforming forces on distal fragment
1. adduction & shortening
◾adductors
Subtrochanteric Fractures
Russel-Taylor Classification
Significance
Russel-Taylor Classification
Type I: No extension into piriformis fossa
Type II: Extension into greater trochanter with involvement of piriformis fossa
• look on lateral xray to identify piriformis fossa extension
Significance:
• Historically used to differentiate between fractures that would amenable to an IMN (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
Subtrochanteric Fractures
Atypical Subtroch
- Major Criteria (5)
- Minor criteria (5)
Four of five major features should be present to designate a fracture as atypical; minor features may or may not be present in individual cases
MAJOR
•Associated with no trauma or minimal trauma, as in a fall from a standing height or less
•Fracture originates at the lateral cortex and is substantially transverse in its orientation, although it may become oblique as it crosses the medial femur
•Noncomminuted
•Complete fractures extend through both cortices and may be associated with a medial spike; incomplete fractures involve only the lateral cortex
• Localized periosteal or endosteal thickening of the lateral cortex is present at the fracture site
MINOR
•Generalized increase in cortical thickness of the femoral diaphyses
•Prodromal symptoms such as dull or aching pain in the groin or thigh
•Bilateral incomplete or complete femoral diaphysis fractures
•Delayed fracture healing
•Specifically excluded are fractures of the femoral neck, intertrochanteric fractures with spiral subtrochanteric extension, pathological fractures associated with primary or metastatic bone tumors, and periprosthetic fractures
Subtrochanteric Fractures Presentation
- History (2)
- Physical exam (2)
- History
◦long history of bisphosphonate or denosumab
◦history of thigh pain before trauma occurred - Physical exam
◦typically associated with obvious deformity (shortening and varus alignment)
◦flexion of proximal fragment may threaten overlying skin
Subtrochanteric FracturesTechniques
•Intramedullary Nailing
◦position ◾lateral positioning post ◾advantages ◾allows for easier reduction of the distal fragment to the flexed proximal fragment
◾allows for easier access to entry portal, especially for piriformis nail
◾supine positioning ◾advantages ◾protective to the injured spine
◾address other injuries in polytrauma patients
◾easier to assess rotation
◦techniques ◾1st generation nail (rarely used)
◾2nd generation reconstruction nail
◾cephalomedullary nail
◾trochanteric or piriformis entry portal ◾piriformis nail may mitigate risk of iatrogenic malreduction from proximal valgus bend of trochanteric entry nail
◦pros ◾preserves vascularity
◾load-sharing implant
◾stronger construct in unstable fracture patterns
◦cons ◾reduction technically difficult ◾nail can not be used to aid reduction
◾fracture must be reduced prior to and during passage of nail
◾may require percutaneous reduction aids or open clamp placement to achieve and maintain reduction
◾mismatch of the radius of curvature ◾nails with a larger radius of curvature (straighter) can lead to perforation of the anterior cortex of the distal femur
◦complications ◾varus malreduction (see complications below)
Techniques
•Intramedullary Nailing
◦position ◾lateral positioning post ◾advantages ◾allows for easier reduction of the distal fragment to the flexed proximal fragment
◾allows for easier access to entry portal, especially for piriformis nail
◾supine positioning ◾advantages ◾protective to the injured spine
◾address other injuries in polytrauma patients
◾easier to assess rotation
◦techniques ◾1st generation nail (rarely used)
◾2nd generation reconstruction nail
◾cephalomedullary nail
◾trochanteric or piriformis entry portal ◾piriformis nail may mitigate risk of iatrogenic malreduction from proximal valgus bend of trochanteric entry nail
◦pros ◾preserves vascularity
◾load-sharing implant
◾stronger construct in unstable fracture patterns
◦cons ◾reduction technically difficult ◾nail can not be used to aid reduction
◾fracture must be reduced prior to and during passage of nail
◾may require percutaneous reduction aids or open clamp placement to achieve and maintain reduction
◾mismatch of the radius of curvature ◾nails with a larger radius of curvature (straighter) can lead to perforation of the anterior cortex of the distal femur
◦complications ◾varus malreduction (see complications below)
Subtrochanteric Fractures: Techniques
Intramedullary Nailing
- position : lateral positioning post
a) advantages - position : ◾supine positioning
a) advantages - Techniques / Options
- Entry point
- lateral positioning
a) advantages
◾allows for easier reduction of the distal fragment to the flexed proximal fragment
◾allows for easier access to entry portal, especially for piriformis nail - supine positioning
a) advantages
◾protective to the injured spine
◾address other injuries in polytrauma patients
◾easier to assess rotation - Techniques
◾1st generation nail (rarely used)
◾2nd generation reconstruction nail
◾cephalomedullary nail - Trochanteric or piriformis entry portal
◾piriformis nail may mitigate risk of iatrogenic malreduction from proximal valgus bend of trochanteric entry nail
Subtrochanteric Fractures: Techniques
Intramedullary Nailing
- Pros (3)
- Cons (2)
- Complications (1)
- pros
◾preserves vascularity
◾load-sharing implant
◾stronger construct in unstable fracture patterns - cons
◾reduction technically difficult- nail can not be used to aid reduction
- fx must be reduced prior to and during nailing
- may require percut reduction aids or open clamp placement to achieve and maintain reduction
◾mismatch of the radius of curvature - nails with a larger radius of curvature (straighter) can lead to perforation of the anterior cortex of the distal femur
- Varus malreduction (see complications)
Subtrochanteric Fractures: Techniques
Fixed angle plate
- approach
- technique
- sliding hip screw is contraindicated due to ________
- Blade plate may function as a ______ construct
- Cons (2)
- lateral approach to proximal femur
◾may split or elevate vastus lateralis off later intermuscular septum
◾dangers include perforating branches of profunda femoris - Technique =95 degree blade plate or condylar screw
- high rate of malunion and failure
- Tension band construct
(femur eccentrically loaded with tensile force on the lateral cortex converted to compressive force on medial cortex) - Cons
i. compromise vascularity of fragments
ii. inferior strength in unstable fracture patterns
Subtrochanteric Fractures: Complications
Complications
- Varus/ procurvatum malunion
◦the most frequent intraoperative complication with antegrade nailing of a subtrochanteric femur fracture is varus and procurvatum (or flexion) malreduction - Nonunion
◦can be treated with plating
◾allows correction of varus malalignment
Subtrochanteric Fractures: Complications
Bisphosphonate fractures
- Nail fixation - increased risk of: (2)
- Plate fixation - increased risk of: (1)
- Nail fixation = increased risk of:
i. Iatrogenic fracture: because of brittle bone and cortical thickening
ii. Nonunion with nail fixation resulting in increased need for revision surgery - Plate fixation = increased risk of:
i. Plate hardware failure: because of varus collapse and dependence on intramembranous healing inhibited by bisphosphonates
Calcaneus Fractures
Epidemiology
1. incidence
2 . _ to _ % open fractures
Pathophysiology
3. mechanism
Associated injuries (orthopaedic)
4. Extension into the calcaneocuboid joint in \_\_\_%
5. Vertebral injuries in \_\_%
6. Contralateral calcaneus in \_\_%
- Prognosis ?
- most frequent tarsal fracture
- 15-20% open
- traumatic axial loading is the primary mechanism (eg. fall from height; MVA)
- 65%
- 10%
- 10%
- Poor prognosis due to 40% complication rate
◾increased due to mechanism (fall from height), smoking, and early surgery
◾lateral soft tissue trauma increases the rate of complication
Calcaneus Fractures
Pathoanatomy (1 of 2)
Intra-articular fractures
◾Primary fracture line results from oblique shear and leads to the following two primary fragments:
1. _____
2. _____
◾Secondary fracture lines
3. dictate whether there is __(a)__ or __(b)__ fracture
◾extra-articular fractures ◾strong contraction of gastrocnemius-soleus with concomitant avulsion at its insertion site on calcaneus
◾more common in osteopenic bone
◾anterior process fractures ◾inversion and plantar flexion of the foot cause avulsion of the bifurcate ligament
- superomedial fragment (constant fragment)
◾includes the sustentaculum tali and is stabilized by strong ligamentous and capsular attachments - Superolateral fragment
◾includes an intra-articular aspect through the posterior facet - Secondary fracture lines dictate whether there is:
a) joint depression
b) tongue-type fracture
Calcaneus Fractures
Pathoanatomy (2 of 2)
- Extra-articular fractures - Mechanism
- Anterior process fractures - Mechanism
- Extra-articular fractures
◾strong contraction of gastrocnemius-soleus with concomitant avulsion at its insertion site on calcaneus
◾more common in osteopenic bone - Anterior process fractures
◾inversion and plantar flexion of the foot cause avulsion of the bifurcate ligament
Calcaneus Fractures
Classification
Anatomical
- Extra-articular (25%) Avulsion of:
a) Anterior process = avulsion of ______ ligament
b) ____________
c) ____________ - Intra-articular (75%)
a Two main classifications ? (eponymous names)(** Full description on separate card **)
- Extra-articular (25%) Avulsion of:
a) anterior process by bifurcate ligament
b) sustentaculum tali
c) calcaneal tuberosity (Achilles tendon avulsion) - Intra-articular (75%)
a) Essex-Lopresti classification
b) Sanders classification
Calcaneus Fractures
Classification : Intra-articular fractures
a) Essex-Lopresti classification - Types / describe
b) Sanders classification - Types / describe
a) Essex-Lopresti classification (first published in 1952).
◾Useful in separating the joint fractures into two types:
i. joint depression
ii. tongue type
◾the primary fracture line runs obliquely through the posterior facet forming two fragments
◾the secondary fracture line runs in one of two planes:
i. ) the axial plane beneath the facet exiting posteriorly in tongue-type fractures (when the superolateral fragment and posterior facet remain attached to the tuberosity posteriorly) ii) behind the posterior facet in joint depression fractures
Calcaneus Fractures
Sanders classification - Types / describe
Sanders classification : based on the number of articular fragments seen on the coronal CT image at the widest point of the posterior facet
Type I • Nondisplaced posterior facet (regardless of number of fracture lines)
Type II • One fracture line in the posterior facet (two fragments)
Type III • Two fracture lines in the posterior facet (three fragments)
Type IV • Comminuted with more than three fracture lines in the posterior facet (four or more fragments)
Calcaneus Fractures : Anatomy
Articular facets
1. ________ fragment contains the articular facets
2. Superior articular surface contains _____ facets that articulate with the talus
3. ________ facet is the largest and is the major weight bearing surface
4 The ___ tendon runs just inferior Posterior facet and can be injured with errant drills/screws that are too long
5. ______ facet is anteromedial on sustentaculum tali
6. ______facet is often confluent with middle facet
- Superolateral
- Three
- Posterior
- Flexor hallucis longus (FHL) tendon
- Middle
- Anterior
Calcaneus Fractures : Anatomy
Sinus tarsi
1. between the __(a)__ and __(b)__ facets lies the interosseous sulcus (calcaneal groove).
- The calcaneal groove (below) and _________ (above) make up the sinus tarsi
- Sustentaculum tali
a. projects medially and supports the _____ of talus
b. ____ passes beneath it
c. ______ and _______ lig connect it to the talus
d. contained in the _______ fragment, which remains “constant” due to medial talocalcaneal and interosseous ligaments
1a. middle
1b. posterior
2. Talar sulcus
3a. Neck
3b. FHL
3c. Deltoid and talocalcaneal ligament
3d. Anteromedial fragment
Calcaneus Fractures : Anatomy
What is the bifurcate ligament ?
Bifurcate ligament : connects the dorsal aspect of the anterior process to the cuboid and navicular (lateral)
** note: avulsed in anterior process fractures
Calcaneus Fractures : imaging
Radiographs ◦recommended views
- Optional views
a) Broden
b) Harris
- Recommended views
◾AP ◾lateral ◾oblique - Optional views
a) Broden
- allows visualization of posterior facet
- useful for evaluation of intraop reduction of posterior facet
- with ankle in neutral dorsiflexion and ~45 degrees internal rotation, take x-rays at 40, 30, 20, and 10 degrees cephalad from neutral - Harris
◾visualizes tuberosity fragment widening, shortening, and varus positioning
◾place the foot in maximal dorsiflexion and angle the x-ray beam 45 degrees
Calcaneus Fractures : imaging
Findings
1. What is ‘double-density’ sign
◾indicates partial separation of facet from sustentaculum
- Valgus OR Varus tuberosity deformity ?
- Bohlers angle decreased
4 . Gissane angle increased
- Represents subtalar incongruity : indicates partial separation of facet from sustentaculum
- Varus tuberosity deformity
- Bohler angle = angle btwn line from highest point of anterior process to highest point of posterior facet + line tangential to superior edge of tuberosity
◾measured on lateral view
◾normal 20-40°
◾represents collapse of the posterior facet - Gissane = angle between line along lateral margin of posterior facet + line anterior to beak of calcaneus
◾measured on lateral view
◾normal 120-145°
◾represents collapse of the posterior facet
Calcaneus Fractures
Non-op with cast immobilization with nonweightbearing for 10 to 12 weeks
a) indications
b) techniques
a) indications
◾small extra-articular fracture (<1 cm) with intact Achilles tendon and <2 mm displacement
◾Sanders Type I (nondisplaced)
◾anterior process fracture involving <25% of calcaneocuboid joint
◾comorbidities that preclude good surgical outcome (smoker, diabetes, PVD)
b) techniques
◾begin early range of motion exercises once swelling allows
Calcaneus Fractures
Operative (1 of 3)
closed reduction with percutaneous pinning
- indications
◾minimally displaced tongue-type fxs or those with mild shortening
◾large extra-articular fractures (>1 cm)
◾early reduction prevents skin sloughing and need for subsequent flap coverage - techniques
◾lag screws from posterior superior tuberosity directed inferior and distal
Calcaneus Fractures
Operative (2 of 3)
ORIF
- indications
- timing
ORIF
1. indications
◾displaced tongue-type fractures
◾large extra-articular fractures (>1 cm) with detachment of Achilles tendon and/or > 2 mm displacement
** urgent if skin is compromised **
◾Sanders Type II and III
-> posterior facet displacement >2 to 3 mm, flattening of Bohler angle, or varus malalignment of the tuberosity
◾anterior process fracture with >25% involvement of calcaneocuboid joint
◾displaced sustentaculum fractures
Timing
◾wait 10-14 days until swelling and blisters resolve and wrinkle sign present 10-14 days
◾no benefit to early surgery due to significant soft tissue swelling
Calcaneus Fractures
Calcaneus Fractures
Operative (3 of 3)
ORIF
- Outcomes
a) surgical outcome correlates with ________ ?
- outcomes
a) Number of intra-articular fragments and the quality of articular reduction
b) Factors associated with a poor outcome: ◾age > 50 ◾obesity ◾manual labor ◾workers comp ◾smokers ◾bilateral calcaneal fractures ◾multiple trauma ◾vasculopathies ◾men do worse with surgery than women
c) Factors associated with most likely need for a secondary subtalar fusion:
- male worker’s compensation patient who participates in heavy labor work with an initial Böhler angle less than 0 degrees
Calcaneus Fractures
Primary subtalar arthrodesis
primary subtalar arthrodesis
- indications
◾Sanders Type IV - techniques
◾combined with ORIF to restore height
Calcaneus Fractures
Surgical Techniques
Approaches & goals (2)
- ORIF with extensile lateral or medial
a.) Extensile lateral L-shaped incision
Goals:
b) ORIF with sinus tarsi approach and Essex-Lopresti maneuver
Calcaneus Fractures
Surgical Techniques
Approaches
ORIF with extensile lateral or medial approach
Approach
◾extensile lateral L-shaped incision is most popular
- provides access to CC-joint and ST joint
- high rate of wound complications
◾medial approach can also be used
- full-thickness flap is created to maintain soft tissue integrity
Technique
◾place a pin in the tuberosity to assist the reduction
◾provisional fixation with Kirschner wires
◾hold reduction with low profile implants
◾bone grafting provides no added benefit
Postoperative care
◾bulky posterior U splint
◾early supervised subtalar range of motion exercises
◾nonweightbearing for 10 weeks
Calcaneus Fractures
Surgical Techniques
ORIF with sinus tarsi approach and Essex-Lopresti maneuver
- Technique
ORIF with sinus tarsi approach and Essex-Lopresti maneuver ◦technique ◾manipulate the heel to increase the calcaneal varus deformity
◾plantarflex the forefoot
◾manipulate the heel to correct the varus deformity with a valgus reduction
◾stabilize the reduction with percutaneous K-wires or open fixation as described above
Calcaneus Fractures
Complications (6)
- Wound complications (10-25%)
◦increased risk in smokers, diabetics, and open injuries - Subtalar arthritis ◦increased with nonoperative management
- Lateral impingement with peroneal irritation
- Damaged FHL
◦at risk with placement of lateral to medial screws, especially at level of sustentaculum tali (constant fragment) - Compartment syndrome (10%)
◦results in claw toes - Malunion
◾loss of height, widening, and lateral impingement
Calcaneus Fractures
Complications
Malunions (1 of 2)
◾loss of height, widening, and lateral impingement
- Physical exam
◾limited ___________
◾due to dorsiflexed talus with talar declination angle <20 - Classification
- Ankle dorsiflexion
◾ due to dorsiflexed talus with talar declination angle <20) - Classification (see below)
Type I • Lateral exostosis with no subtalar arthritis • Treat with lateral wall resection
Type II • Lateral exostosis with subtalar arthritis • Treat with lateral wall resection and subtalar fusion
Type III • Lateral exostosis, subtalar arthritis, and varus malunion • Treat with lateral wall resection, subtalar fusion, and +/- valgus osteotomy (controversial)
Calcaneus Fractures
Complications
Malunions (2 of 2)
- Treatment: distraction bone block subtalar arthrodesis
◾indications: (4)
◾technique : goal is to correct (4)
- Treatment: distraction bone block subtalar arthrodesis
◾indications:
- chronic pain from subtalar joint
- incongruous subtalar joint/PTOA
- loss of calcaneal height
- mechanical block to ankle dorsiflexion
- -> results from post talar collapse into the posterior calcaneus
◾technique : goal is to correct
- hindfoot height - ankle impingement - subfibular impingement - subtalar arthritis
Tibia Shaft Fractures
Incidence
Epidemiology
◦most common long bone fx
◦account for 4% of all fx seen in the Medicare population
Tibia Shaft Fractures
Mechanism i.) Low energy fx pattern ◾result of torsional injury ◾indirect trauma results in spiral fx ◾fibula fx at different level ◾Tscherne grade 0 / I soft tissue injury
ii.) High energy fx pattern
◾direct forces often result in wedge or short oblique fx and sometimes significant comminution
◾fibula fx at same level
◾severe soft tissue injury
- Tscherne II / III
- Open fx
Tibia Shaft Fractures
Associated conditions (4)
Associated conditions
1. Soft tissue injury (open wounds)
◾critical to outcome
- Compartment syndrome
- Bone loss
- Ipsilateral skeletal injury
◾extension to the tibial plateau or plafond
◾posterior malleolar fracture
-> most commonly associated with spiral distal third tibia fracture
Tibia Shaft Fractures
Treatment of Closed Tibia Fractures
Nonoperative : Indications
- closed low energy fxs with acceptable alignment (7)
- closed low energy fxs with acceptable alignment
◾< 5 degrees varus-valgus angulation
◾< 10 degrees anterior/posterior angulation
◾> 50% cortical apposition
◾< 1 cm shortening
◾< 10 degrees rotational malalignment
◾if displaced perform closed reduction under general anesthesia
◾certain patients who may be non-ambulatory (ie. paralyzed), or those unfit for surgery
Tibia Shaft Fractures
Treatment of Closed Tibia Fractures
Nonoperative
- technique
- outcomes
- technique
◾place in long leg cast and convert to functional (patellar tendon bearing) brace at 4 weeks - outcomes
◾high success rate if acceptable alignment maintained
◾risk of shortening with oblique fracture patterns- mean shortening is 4 mm
◾risk of varus malunion with midshaft tibia fractures and an intact fibula
◾non-union occurs in 1.1% of patients treated with closed reduction
- mean shortening is 4 mm
Tibia Shaft Fractures
Operative options (3)
- External fixation
◾outcomes : higher incidence of malalignment compared to IM nailing - IM Nailing
- Percutaneous locking plate
Tibia Shaft Fractures
IM Nailing
- indications
- contraindications
- outcomes:
a. ) IM nailing leads to (versus external fixation) decreased ________
b. ) IM nailing leads to (versus closed treatment) ______ time to union
c. ) ________ time to weight bearing - Reamed vs. unreamed nails
a) ________ possibly superior to _______ nails for treatment of closed tibia fxs for decrease in future bone grafting or implant exchange (SPRINT trial)b. ) recent studies show _______ effects of reaming (infection, nonunion)
c. ) reaming with use of a tourniquet (IS / IS NOT) associated with thermal necrosis of the tibial shaft
- indications
◾unacceptable alignment with closed reduction and casting
◾soft tissue injury that will not tolerate casting
◾segmental fx
◾comminuted fx
◾ipsilateral limb injury (i.e., floating knee)
◾polytrauma
◾bilateral tibia fx
◾morbid obesity - Contraindications
◾pre-existing tibial shaft deformity that may preclude passage of IM nail
◾previous TKA or tibial plateau ORIF (not strict contraindication)
3a. malalignment
3b. decreased
3c. decreased
4a. reamed possibly superior to unreamed 4b. recent studies show NO adverse effects of reaming (infection, nonunion)
4c. IS NOT
Tibia Shaft Fractures
Treatment of Open Tibia Fractures
ABx and surgical debridement
1. timing of I&D 2 Antibiotics 3. Outcomes a. \_\_\_\_\_\_\_ is the most important factor in reducing infection b. \_\_\_\_\_\_\_\_\_ also an important factor
- Timing of I&D
◾surgical debridement 6-8 hours after time of injury is preferred
◾grossly contaminated wounds are irrigated in emergency department - Antibiotics
◾cephalosporin given for 24-48 hours in Grade I,II, and IIIA open fractures
◾aminoglycoside added in Grade IIIB injuries- minimal data to support this
◾penicillin administered in farm injuries - minimal data to support this
- minimal data to support this
3a. early antibiotic administration
3b. emergent and thorough surgical debridement (must remove all devitalized tissue including cortical bone)
Tibia Shaft Fractures
Approaches
Approach
1. medial parapatellar
◾most common starting point
◾can lead to valgus malalignment when used to treat proximal fractures
2. lateral parapatellar
◾helps maintain reduction when nailing proximal 1/3 fractures
◾requires mobile patella
3. patellar tendon splitting
◾gives direct access to start point
◾can damage patellar tendon or lead to patella baja (minimal data to support this)
4. semiextended medial or lateral parapatellar
◾used for proximal and distal tibial fractures
5. suprapatellar (transquadriceps tendon
◾requires special instruments
◾can damage patellofemoral joint
Tibia Shaft Fractures
Starting point
Starting point
1. medial parapatellar tendon approach with knee flexed
◾incision from inferior pole of patella to just above tibial tubercle
◾identify medial edge of patellar tendon, incise
◾peel fat pad off back of patellar tendon
◾starting guidewire is placed in line with medial aspect of lateral tibial spine on AP radiograph, just below articular margin on lateral view
- semiextended lateral or medial parapatellar approach
◾skin incision made along medial or lateral border of patella from superior pole of patella to upper 1/3 of patellar tendon
◾knee should be in 5-30 degrees of flexion
◾choice to go medial or lateral is based of mobility of patella in either direction
◾open retinaculum and joint capsule to level of synovium
◾free retropatellar fat pad from posterior surface of patellar tendon
◾identify starting point as mentioned previously
Tibia Shaft Fractures
Fracture reduction techniques (overview
5)
fracture reduction techniques ◾spanning external fixation (ie. traveling traction) ◾clamps ◾femoral distractor ◾small fragment plates/screws ◾intra-cortical screws
Tibia Shaft Fractures
- Reaming
- Nail insertion
- Locking screws
- Reaming
◾reamed nails superior to unreamed nails in closed fractures
◾be sure tourniquet is released
◾advance reamers slowly at high speed
◾overream by 1.0-1.5mm to facilitate nail insertion
◾confirm guide wire is appropriately placed prior to reaming - Nail insertion
◾insert nail in slight external rotation to move distal interlocking screws anteriorly decreasing risk of NVS injury
◾if nail does not pass, remove and ream 0.5-1.0mm more - Locking screws
◾statically lock proximal and distally for rotational stability (*no indication for dynamic locking acutely)
◾number of interlocking screws is controversial- two proximal and two distal screws in presence of <50% cortical contact
- consider 3 interlock screws in short segment of distal or proximal shaft fracture
Tibia Shaft Fractures
Complications
- Knee pain
a) >__% anterior knee pain with IM nailing
Malunion:
a.high incidence of _____ and ________ (apex anterior) malalignment in proximal third fractures
b. ______ malunion leads to ipsilateral ankle pain and stiffness
c. chronic angular deformity is defined by:
Nonunion
a) definition:
◾delayed union if union at_____.
◾nonunion if no healing after _____.
1a. >50%
◾occurs with patellar tendon splitting and paratendon approach
◾pain relief unpredictable with nail removal
2a.high incidence of valgus and procurvatum (apex anterior) malalignment in proximal third fractures
2b VARUS
2c. The proximal and distal anatomical/mechanical axis of each segment
◾center of rotation of angulation is intersection of proximal and distal axes
- nonunion
◾delayed union if union at 6-9 mos.
◾nonunion if no healing after 9 mos.
Tibia Shaft Fractures
Complications
Nonunion
- treatment
Treatment
◾nail dynamization if axially stable
◾exchange nailing if not axially stable
i. reamed exchange nailing most appropriate for aseptic, diaphyseal tibial nonunions with less than 30% cortical bone loss.
ii. consider revision with plating in metaphyseal nonunions
◾posterolateral bone grafting if significant bone loss
◾non-invasive techniques (electrical stimulation, US)
◾BMP-7 (OP-1) has been shown equivalent to autograft
i. often used in cases of recalcitrant non-unions
◾compression plating has been shown to have 92-96% union rate after open tibial fractures initially treated with external fixation
◾fibular osteotomy of tibio-fibular length discrepancy associated with healed or intact fibula
Tibia Shaft Fractures
Complications
Malrotation
Malrotation
◦most commonly occurs after IM nailing of distal 1/3 fractures
◦can assess tibial rotation by obtaining perfect lateral fluoroscopic image of knee, then rotating c-arm 105-110 degrees to obtain mortise view of ipsilateral ankle
◦reduced risk with adjunctive fibular plating
Ankle Fractures
Radiographs
- recommended views
- External rotation stress
- indications
- Recommended views
- External rotation stress
- most appropriate stress radiograph to assess competency of deltoid ligament
- more sensitive to injury than medial tenderness, ecchymosis, or edema
- gravity stress radiograph is equivalent to manual stress radiograph
note: Full-length tibia, or proximal tibia, to rule out Maisonneuve-type fracture
Ankle Fractures
XR findings : syndesmotic injury
- decreased tibiofibular overlap
a) measure at point of ______ overlap
b) normal >__ mm on AP view
c) normal >__ mm on mortise view - increased medial clear space
a) normal ≤ __mm on mortise or stress view
b) medial clear space of >__mm with external rotation stress applied to a dorsiflexed ankle is predictive of deep deltoid disruption - increased tibiofibular clear space
a) measure clear space ___ mm above joint
b) normal
- decreased tibiofibular overlap
a. measure at point of maximum overlap
b. normal >6 mm on AP view
c. normal >1 mm on mortise view
*** note: it has also been reported that there is no actual correlation between syndesmotic injury and tibiofibular clear space or overlap measurements
2a. normal ≤ 4 mm on mortise or stress view
2b. medial clear space of >5mm with external rotation stress applied to a dorsiflexed ankle is predictive of deep deltoid disruption
3a. measure clear space 10 mm above joint
3b. normal <6 mm on both AP and mortise views
Ankle Fractures
XR findings : lateral malleolus fractures
- talocrural angle
talocrural angle
◾measured by bisection of line through tibial anatomical axis and another line through the tips of the malleoli
◾shortening of lateral malleoli fractures can lead to increased talocrural angle
◾talocrural angle is not 100% reliable for estimating restoration of fibular length
◾can also utilize the realignment of the medial fibular prominence with the tibiotalar joint
Ankle Fractures
XR findings : posterior malleolus fractures (2)
posterior malleolus fractures
◾double contour sign
◾misty mountains sign
Ankle Fractures
Lauge-Hansen Classification (1 of 2)
4 types and patterns
- Supination - Adduction (SA)
- Talofibular sprain or distal fibular avulsion
- Vertical medial malleolus and impaction of anteromedial distal tibia
- Supination - External Rotation (SER)
- Anterior tibiofibular ligament sprain
- Lateral short oblique fibula fracture (anteroinferior to posterosuperior)
- Posterior tibiofibular ligament rupture or avulsion of posterior malleolus
- Medial malleolus transverse fracture or disruption of deltoid ligament
- Pronation - Abduction (PA)
- Medial malleolus transverse fracture or disruption of deltoid ligament
- Anterior tibiofibular ligament sprain
- Transverse comminuted fracture of the fibula above the level of the syndesmosis
- Pronation - External Rotation (PER)
- Medial malleolus transverse fracture or disruption of deltoid ligament
- Anterior tibiofibular ligament disruption
- Lateral short oblique or spiral fracture of fibula (anterosuperior to posteroinferior) above the level of the joint
- Posterior tibiofibular ligament rupture or avulsion of posterior malleolus
Ankle Fractures
General Treatment
Nonoperative : indications
Indications
◾isolated nondisplaced medial malleolus fracture or tip avulsions
◾isolated lateral malleolus fracture with < 3mm displacement and no talar shift
◾bimalleolar fracture if elderly or unable to undergo surgical intervention
◾posterior malleolar fracture with < 25% joint involvement or < 2mm step-off
technique
◾goal of treatment is stable anatomic reduction of talus in the ankle mortise
◾1 mm shift of talus leads to 42% decrease in tibiotalar contact area
Ankle Fractures
General Treatment : operative
Outcomes
Outcomes
◾overall success rate of 90%
-> prolonged recovery expected (2 years to obtain final functional result)
◾significant functional impairment often noted
◾worse outcomes with: smoking, decreased education, alcohol use, increased age, presence of medial malleolar fracture
◾ORIF superior to closed treatment of bimalleolar fractures
◾in Lauge-Hansen supination-adduction fractures, restoration of marginal impaction of the anteromedial tibial plafond leads to optimal functional results after surgery
Ankle Fractures
Driving
◾time for proper braking response time (driving) returns to baseline at nine weeks for operatively treated ankle fractures
◾braking travel time is significantly increased until 6 weeks after initiation of weight bearing in both long bone and periarticular fractures of the lower extremity
Ankle Fractures
Isolated Medial Malleolus Fracture
- Nonoperative
a. indications - Operative
a. indicationsb. technique
Nonoperative
a) indications
◾nondisplaced fracture and tip avulsions ◾deep deltoid inserts on posterior colliculus
◾symptomatic treatment often appropriate
- Operative
a) indications
◾any displacement or talar shift
b) technique
◾lag screw fixation ◾lag screw fixation stronger if placed perpendicular to fracture line
◾antiglide plate with lag screw ◾best for vertical shear fractures
◾tension band fixation ◾utilizing stainless steel wire
Ankle Fractures
Isolated Lateral Malleolus Fracture
- Nonoperative :indications
- Nonoperative :indications
◾if intact mortise, no talar shift, and < 3mm displacement
◾classically fractures with more than 4-5 mm of medial clear space widening on stress radiographs have been considered unstable and need to be treated surgically
i.) recent studies have shown the deep deltoid may be intact with up to 8-10 mm of widening on stress radiographs
ii.) if the mortise is well reduced, results from operative and non-operative treatment are similar
Ankle Fractures
Isolated Lateral Malleolus Fracture
Operative
- indications
- Indications
◾if talar shift or > 3 mm of displacement
◾can be treated operatively if also treating an ipsilateral syndesmosis injury - Technique ORIF: plate placement
a. lateral
◾lag screw fixation with neutralization plating
◾bridge plate technique
b. Posterior
◾antiglide technique
◾lag screw fixation with neutralization plating
◾most common disadvantage of using posterior antiglide plating is peroneal irritation if the plate is placed too distally
Ankle Fractures
Isolated Lateral Malleolus Fracture
Operative
- options other than plate ORIF
- Medial mall fixation
- Post-operative care
- Options
- intramedullary retrograde screw placement
- isolated lag screw fixation
◾possible if fibula is a spiral pattern and screws can be placed at least 1 cm apart - Fixation of medial malleolus fracture ◾for transverse pattern, lag by technique using 3.5 fully-threaded screw is biomechanically superior to lag by design using 4.0 partially-threaded screws
- Post-operative care
◾period of immobilization usually 4-6 weeks after ORIF
◾duration of immobilization should be doubled in Diabetic patients
Ankle Fractures
Medial and Lateral (Bimalleolar) Fracture
- Nonoperative: indications
- Operative : indications
- Operative : technique
a. fibula
b. medial malleolus : fixation options (4)
- Nonoperative : indications
◾elderly or unable to undergo surgical intervention - Operative ◦ORIF : indications
◾any lateral talar shift
3a. Fibula
◾need to fix with one of the options listed in section above
3b. Medial malleolus : fixation options ◾cancellous lag screws
◾bicortical screws
◾tension band wiring
◾antiglide plate to treat a vertical medial malleolus fracture
** note: orient screws parallel to joint for vertical medial malleolar fracture (Lauge-Hansen supination-adduction fracture pattern) **
Ankle Fractures
Functional Bimalleolar Fracture (deltoid ligament tear with fibular fracture)
a. Operative : indications
b. Technique
- Operative : indications
◾examination has been shown to be largely unreliable in predicting medial injury
◾can see significant lateral translation of the talus in this pattern
b. Technique
◾not necessary to repair medial deltoid ligament
◾only need to explore medially if you are unable to reduce the mortise
** see isolated fibular fracture techniques
Ankle Fractures
Posterior Malleolar Fracture
- Non-Operative : indications
- indications
◾< 25% of articular surface involved- evaluation of percentage should be done with CT, as plain radiology is unreliable
◾< 2 mm articular stepoff
◾syndesmotic stability
Ankle Fractures
Posterior Malleolar Fracture
Operative ◦ORIF
1. indications (3)
- Technique : Approach (2)
- Fixation options (3)
- Syndesmosis injury
a. stiffness of syndesmosis restored to __% normal with isolated fixation of posterior malleolus (versus 40% with isolated syndesmosis fixation)
b. stress examination of syndesmosis ____ required after posterior malleolar fixation
- Indications
◾> 25% of articular surface involved
◾> 2 mm articular stepoff
◾syndesmosis injury - Technique : Approach
i. posterolateral approach
ii. posteromedial approach
(note: decision of approach will depend on fracture lines and need for fibular fixation) - Fixation options
i. AP lag screws to capture fragment (if nondisplaced)
ii. PA lag screw and buttress plate
iii. antiglide plate
4a. 70%
4b. still required
** note : posteroinferior tibiofibular ligament may remain attached to posterior malleolus and syndesmotic stability may be restored with isolated posterior malleolar fixation
Ankle Fractures
What is a Bosworth Fracture-Dislocation
Overview
◦rare fracture-dislocation of the ankle where the fibula becomes entrapped behind the tibia and becomes irreducible
◦posterolateral ridge of the distal tibia hinders reduction of the fibula
Operative
◦open reduction and fixation of the fibula in the incisura fibularis
◾indicated in most cases
Ankle Fractures :Bosworth Fracture-Dislocation
hyperflexion variant ?
Overview
◦fracture-dislocation of the ankle due to hyperplantarflexion
◦main feature is a vertical shear fracture of the posteromedial tibial rim
◦”spur sign” is a double cortical density at the inferomedial tibial metaphysis
Operative
◦fixation of posteromedial and posterior fragments with antiglide plating
Open Ankle Fracture
Operative
- emergent operative debridement and ORIF
a. indicated if ______
b. primary closure at the index procedure if? - external fixation :indications
Open Ankle Fracture
1. Emergent operative debridement and ORIF indicated if soft tissue conditions allow
b. primary closure at the index procedure can be performed in appropriately-selected Gustilo-Anderson grade I, II, and IIIA open fractures in otherwise healthy patients sustaining low-energy injuries without gross contamination
- external fixation: indications
◾soft tissue conditions and overall patient characteristics
Ankle Fracture
Associated Syndesmotic Injury
Suspect injury in all ankle fractures
a. most common in Weber __ fracture patterns
b. fixation usually not required when fibula fracture within ____cm of plafond
c. Up to ___% of tibial shaft fractures will have ankle injury
a. Weber C fracture
b. 4.5 cm
c. up to 25%
Ankle Fracture
Associated Syndesmotic Injury
Evaluation
Evaluation
◾measure clear space 1 cm above joint
- it has also been reported that there is no actual correlation between syndesmotic injury and tibiofibular clear space or overlap measurement
- lateral stress radiograph has more interobserver reliability than an AP/mortise stress film
◾ best option is to assess stability intraoperatively with abduction/external rotation stress of dorsiflexed foot
◾ instability of the syndesmosis is greatest in the anterior-posterior direction
Ankle Fracture
Associated Syndesmotic Injury
Treatment : operative
- Syndesmotic screw fixation
a. indications
Treatment : operative
- Syndesmotic screw fixation
a. indications
◾widening of medial clear space
◾tibiofibular clear space (AP) greater than 5 mm
◾tibiofibular overlap (mortise) narrowed
◾any postoperative malalignment or widening should be treated with open debridement, reduction, and fixation
Ankle Fracture
Associated Syndesmotic Injury
Treatment : operative
Syndesmotic screw fixation
- technique
- Technique
◾length and rotation of fibula must be accurately restored
◾outcomes are strongly correlated with anatomic reduction- placing reduction clamp on midmedial ridge and the fibular ridge at the level of the syndesmosis willa chieve most reliable anatomic reduction
◾”Dime sign”/Shentons line to determine length of fibula
◾open reduction required if closed reduction unsuccessful or questionable
◾one or two cortical screw(s) 2-4 cm above joint, angled posterior to anterior 20-30 degrees
◾lag technique not desired
◾maximum dorsiflexion of ankle not required during screw placement (can’t overtighten a properly reduced syndesmosis)
- placing reduction clamp on midmedial ridge and the fibular ridge at the level of the syndesmosis willa chieve most reliable anatomic reduction
Ankle Fracture
Associated Syndesmotic Injury
Treatment : operative
Syndesmotic screw fixation
- postoperative
postoperative
◾screws should be maintained in place for at least 8-12 weeks
◾must remain non-weight bearing, as screws are not biomechanically strong enough to withstand forces of ambulation
Ankle Fracture
Associated Syndesmotic Injury
Treatment : operative
Syndesmotic screw fixation
- controversies
controversies
1. number of screws
◾1 or 2 most commonly reported
- number of cortices
◾3 or 4 most commonly reported - size of screws
◾3.5 mm or 4.5 mm screws - implant material (stainless steel screws, titanium screws, suture, bioabsorbable materials)
- need for hardware removal
◾no difference in outcomes seen with hardware maintenance (breakage or loosening) or removal at 1 year
◾outcome may be worse with maintenance of intact screws
Diabetic Ankle Fractures (with or without Neuropathy)
- Risks (3)
- Enhanced fixation
- Post-op
- Risks
i. prolonged healing
ii. high risk of hardware failure
iii. high risk of infection - Enhanced fixation
◦multiple quadricortical syndesmotic screws (even in the absence of syndesmotic injury)
◦tibiotalar Steinmann pins or hindfoot nailing
◦ankle spanning external fixation
◦augment with intramedullary fibula K-wires
◦stiffer, more rigid fibular plates (instead of 1/3 tubular plates)
◾compression plates
◾small fragment locking plates - Delay weightbearing
◦maintain non-weightbearing postop for 8-12 weeks (instead of 4-8 weeks in normal patients
Ankle Fracture
Complications (4)
Complications
- Wound problems (4-5%)
- Deep infections (1-2%)
◦up to 20% in diabetic patients: largest risk factor for diabetic patients is presence of peripheral neuropathy - Malunion
◦high suspicion for articular impaction of the tibial plafond in supination-adduction injuries, which should be addressed at the time of surgery - Post-traumatic arthritis
◦ rare with anatomic reduction and fixation
◦ corrective osteotomy requires anatomic fibular and mortise correction for optimal outcomes
Distal Femur Fractures
Epidemiology
Mechanism
Epidemiology
◦traditionally young patients but increasing in geriatric population
◦bimodal distribution: young, healthy males, elderly osteopenic females
◦periprosthetic fractures becoming more common
Mechanism
◦young patients ◾high energy with significant displacement
◦older patients ◾low energy, often fall from standing, in osteoporotic bone, usually with less displacement
Distal Femur Fractures
Anatomy
- Osteology
- Pathomechanics - defoming forces
- Osteology
◦distal femur becomes trapezoidal in cross section towards knee
◦medial condyle extends more distal than lateral
◦posterior halves of both condyles are posterior to posterior cortex of femoral shaft
◦anatomical axis of distal femur is 6-7 degrees of valgus
◦lateral cortex of femur slopes ~10 degrees, medial cortex slopes ~25 degrees in axial plane
Distal Femur Fractures
Pathomechanics - defoming forces
EXTENDED - SHORTENED - VARUS
i. gastrocnemius: extends distal fragment (apex posterior)
ii. hamstring and extensor mechanism: cause shortening
iii. adductor magnus: leads to distal femoral varus
Distal Femur Fractures
What is a ‘Hoffa fracture’ ?
◾intra-articular distal femoral fracture in the coronal plane
◾may be seen on lateral view
Distal Femur Fractures
CT (obtain with coronal and sagittal reconstructions)
- Useful for (4)
- Angiography : indications
- Useful for
i. establishing intra-articular involvement
ii. identifying separate OCD in the area of the intercondylar notch
iii. identifying coronal plane fracture (Hoffa fracture) post- ** note 38% incidence of Hoffa fx in Type C fx’s ***
iv. preoperative planning
- ** note 38% incidence of Hoffa fx in Type C fx’s ***
- Angiography
◦indicated when diminished distal pulses after gross alignment restored
◦consider if associated with knee dislocation
Distal Femur Fractures
Treatment - Nonoperative
Indications
- Indications (rare)◾nondisplaced fractures◾nonambulatory patient◾patient with significant comorbidities presenting unacceptably high degree of surgical/anesthetic risk
Distal Femur Fractures
Operative (1 of 3)
- Options (4)
- External fixation (details)
- Ex-Fix / ORIF / retrograde nail / distal femur replacement
- External fixation
◾temporizing measure until soft tissues permit internal fixation, or until patient is stable
◾avoid pin placement in area of planned plate placement if possible
Distal Femur Fractures
Operative (2 of 3)
ORIF
a. indications
b. goals
c. post op
- open reduction internal fixation
a. indications
◾displaced fracture
◾intra-articular fracture
◾nonunion
b. goals
◾need anatomic reduction of joint
◾stable fixation of articular component to shaft to permit early motion
◾preserve vascularity
c. postoperative
◾early ROM of knee important
◾non-weight bearing or toe touch weight-bearing for 6-8 weeks, up to 10-12 weeks if comminuted
◾quadriceps and hamstring strength exercises
Distal Femur Fractures
- Operative (3 of 3)
- Retrograde IM nail
a. indications
- Retrograde IM nail
a.indications
◾good for supracondylar fx without significant comminution
◾preferred implant in osteoporotic bone
◾traditionally, 4 cm of intact distal femur needed but newer implants with very distal interlocking options may decrease this number, can perform independent screw stabilization of intercondylar component of fracture around nail - Distal femoral replacement
a. indications
◾unreconstructable fracture
◾fracture around prior TKR with loose component
Distal Femur Fractures
Operative : ORIF Approaches (4)
ORIF Approaches
1. anterolateral
◾fractures without articular involvement or with simple articular extension
◾incision from tibial tubercle to anterior 1/3 of distal femoral condyle
◾extend up midlateral femoral shaft as needed
◾minimally invasive plate osteosynthesis: small lateral incision, slide plate proximally, use stab incisions for proximal screw placement
- lateral parapatellar
◾fractures with complex articular extension
◾extend incision into quad tendon to evert patella
◾can be used for Hoffa fracture - medial parapatellar
◾typical TKA approach
◾used for complex medial femoral condyle fractures - medial/lateral posterior
◾used for very posterior Hoffa fragment fixation
◾patient placed in prone position
◾midline incision over popliteal fossa
◾develop plane between medial and lateral gastrocnemius m.
◾capsulotomy to visualize fracture
Distal Femur Fractures
Operative : Retrograde interlocked IM nail
- Approach
- Pros
- Cons
- approach : medial parapatellar
◾ no articular extension present- 2.5 cm incision parallel to medial aspect of patellar tendon
- stay inferior to patella
- no attempt to visualize articular surface
◾articular extension present - continue approach 2-8 cm cephalad
- incise extensor mechanism 10 mm medial to patella
- eversion of patella not typically necessary
- need to stabilize articular segments prior to nail placement
- pros ◾requires minimal dissection of soft tissue
- cons
◾less axial and rotational stability
◾postoperative knee pain
Distal Femur Fractures
Complications (5)
- Symptomatic hardware
- Malunions
- Nonunions
- Infection
- Implant failure (9%)
Distal Femur Fractures: Complications (details)
- Symptomatic hardware
a. Lateral caused by:
b. Medial caused by:
c. Determine screw length with II on AP with leg ____ rotated 30 deg - Malunions
a. most commonly assoc. with plating, usually valgus/varus?
b. functional results satisfactory if malalignment is within ____ degrees in any plane - Nonunions
a. up to 19%,
b. most commonly in ______ area, with articular portion healed - Infection
- Implant failure
a. up to __%
b. titanium OR stainless steel superior
c. most likely due to improper ________ techniques
- Symptomatic hardware
a. pain with knee flexion/extension due to IT band contact with plate
b. long screws can irritate medial soft tissues
c. internally rotated 30 degrees - Malunions
a. varus
b. 5 degrees - Nonunions
a. 19%,
b. metaphyseal area, with articular portion healed (comminution, bone loss and open fractures more likely in metaphysis)
Note: consider changing fixation technique to improve biomechanics
