Thigh Injury Flashcards
1
Q
Learning outcome:
A
- Neck of femur fracture
- Intertrochanteric fracture
- Subtrochanteric fracture
- Isolated greater/lesser trochanter fracture
- Femoral shaft fracture
2
Q
Femoral neck fracture pathology
A
- Epidemiology
- commonest in elderly - Risk factors
- elderly
- osteoporosis
- menopause
- female
3. Types I. Subcapital* II. Transcervical* III. Base *poor healing because of tearing or retinacular artery and synovial fluid prevents haematoma formation
- Mechanism of injury
- trivial fall in sitting position (elderly)
- fall from height (young)
- stress fracture (overused) - Garden Classification
*increase severity of non-union, avn
I. incomplete, undisplaced
II. complete, undisplaced
III. partial displacement
IV. total displacement - Pauwell’s Classification
* Higher verticality, higher sheer force, higher unstability
I: Oblique fracture line <30 degree (Stable)
II: Oblique fracture line 30-50 degree (Less Stable)
III: Oblique fracture line >50 degree (Unstable)
3
Q
Femoral neck fracture diagnosis
A
Hx
- trauma: fall in sitting position, from height, mva
- pain: proximal thigh/hip
- defomity: shortening, externally rotated
- disability: cannot weightbear (can if impacted, undisplaced)
Pe
- tenderness proximal thigh
- limb externally rotated
- tenderness with hip flexion or internal rotation
X-Ray - AP: continuity of femoral and supraacetsabular trabeculae lines I. same or slight valgus femoral head II. same III. perpendicular Iv. paralled but not in continuity - lateral: displacement, angulation
MRI/Bone scan
- stress fracture (no X-Ray findings)
4
Q
Intertrochanteric fracture pathology
A
- Rf: same as neck of femur
- Mechanism of injury:
- fall in sitting position
- twisted (externally rotated)
- pathological (multiple myeloma, osteoporosis) - Kyle’s Classification
*increase instability and difficulty to reduce
I. simple, not displaced
II. lesses trochanter fracture, minimal comminution, displaced
III. greater trochanter fracture, comminuted, displaced
IV. subtrochanteric extension, severely comminuted, displaced
5
Q
Subtrochanteric fracture pathology
A
- Mechanism of injury
- high-energy injury in young (strengthen by widening cortex and stout pillar)
- trivial fall in adult (pathological) - Associated injury
I. anostomoding branch of medial and lateral circumflex (more blood loss)
II. malunion deforming force:
- proximal fragment abduction: gluteus medius, minimus
- proximal fragment flexion: illiopsoas
- proximal fragment external rotation: piriformis
- distal fragment adduction: thigh adductors - Russel-Taylor Classification
Ia: Do not extend into piriformis
Ib: Do not extend into piriformis + comminution of lesser trochanter
IIa: Extend to greater trochanter and piriformis
IIB: Extend to greater trochanter and piriformis + comminution of lesser trochanter
5
Q
Subtrochanteric fracture diagnosis
A
Hx :
- trauma
- bisphonate usage
- pain excruciating with any movement, unable to weightbear
- deformity: externally rotated, shortened
- marked swelling of the thigh
Pe:
- shortening, varus alignment
- skin tenting due to proximal fragment
X-ray:
- AP:
- fracture below lesser trochanter (within 5 cm)
- upper fragment is flexed, appears short
- shaft adducted, displaced proximally - Important features (affecting reduction)
I. fracture extension to piriform fossa and greater trochanter
II. displacement of medial fragment and lesser trochanter
III. lytic lesion in femur - Biphosphonate findings
- lateral cortical thickening
- transverse fracture
- medial spike
- lack comminution
6
Q
Intertrochanteric fracture diagnosis
A
Hx
- trauma: fall in sitting position, from height, mva
- pain: proximal thigh/hip
- defomity: shortening, externally rotated (more than in neck fracture because extracapsular)
- disability: cannot weightbear
Pe
- tenderness proximal thigh
- limb externally rotated
- tenderness with hip flexion or internal rotation (unable to)
X-Ray
- AP: fracture line crosses greater to lesse trochanter
- lateral: displacement, angulation
7
Q
Differential diagnosis of proximal thigh pain?
A
- Neck of femur fracture (subcapital/transcervical/base)
- Intertrochanteric fracture
- Subtrochanteric fracture
- Isolated greater trochanteric fracture
- Acetabulum fracture
- Hip dislocation (anterior/posterior)
- Pathological fracture (osteoporosis)
8
Q
Classification of neck of femur fracture?
A
Based on location:
- Subcapital
- Transcervical
- Base
For management:
- Garden’s classification
- Pauwel’s classification
9
Q
Garden’s Classification of neck of femur fracture?
A
Type 1 - incomplete fracture
Type 2 - Complete fracture with no displacement
Type 3 - Complete fracture with displacement (trabecular pattern disrupted)
Type 4 - Complete fracture with displacement(trabecular pattern maintained/parallel)
10
Q
Significance of Garden’s classification?
A
- Communication
- Management
- Prognosis: Higher degree of displacement, higher risk of blood supply disruption, higher risk for non-union or AVN
12
Q
Pauwel’s Classification of neck of femur fracture?
A
Type 1: Oblique fracture line <30 degree (Stable)
Type 2: Oblique fracture line 30-50 degree (Less Stable)
Type 3: Oblique fracture line >50 degree (Unstable)
(Higher verticality, higher sheer force, higher unstability)
13
Q
Femoral shaft fracture pathology
A
- Features
- difficult to be reduced (large muscle attachment)
- Easy healing (well vascularized)
- Easy wound cover (lots of skin) - Mechanism of injury
i. twisting: spiral
ii. direct: oblique/transverse
iii. high-energy: comminuted, segmental - Fracture displacement
I. Proximal shaft: same like subtrochanteric fracture
II. Mid-shaft: same, but abduction is less marked
III. Lower third: proximal fragment adducted, distal tilted by gastrocnemius pull - Complication
- profunda femoris cut
- femoral artery cut (distal third shaft fracture) - Winquist’s Classification
(higher instability and soft tissue injury with higher comminution)
I. Tiny cortical fragment
II. Larger butterfly fragment but more than 50% cortical contact between fragments
III. Less than 50% cortical contact between fragment
IV. Segmental fracture
