Traumatology of lower limb I. Hip joint, femur, patella [USEMAP] Hip joint - anatomy img039 [USEMAP] Blood supply of proximal femur img040a [USEMAP] Geometry of acetabulum and femur img041b img041b [USEMAP] Luxatio femoris – hip dislocation •Mechanism – high energy trauma, extensive indirect force – car accidents /dash board injury/, falls • •Very often with fracture of acetabulum or femur • •Dg – intense pain, springy resistance, limb possition depending on luxation type, • x-ray – both hips, beware undisplaced femoral neck fr., CT. • •Risks • - posterior dislocation - n.ischiadicus, • - anterior dislocation - n.femoralis and a.femoralis. • - all cases – vitality of femoral head /avascular necrosis – 20%, after 12hours of dislocation – above 50%/ [USEMAP] Hip dislocations •Posterior – more frequent /90%/, mechanism - adduction, limb in internal rotation, shorter • • – upper – luxatio iliaca • - lower – luxatio ischiadica • •Anterior – /10%/ -mechanism - abduction, limb in external rotation, normal lenght or longer • – upper – luxatio pubica /iliopectinea/ • - lower – luxatio obturatoria • • „central dislocation“ - fracture of acetabular centr • • • • • • • [USEMAP] Anterior hip dislocation [USEMAP] Posterior hip dislocation [USEMAP] Therapy •Reduction • - urgent, under general anesthesia with muscle relaxation, • - x-ray control • - CT – before or after reduction • - neurovascular status – check and document pre and post • •Operating treatment – unstabile or nonreducible fractures – advantage – early mobilization, disadvantage – difficult aproach. • • [USEMAP] Posterior disloc.- reduction - flexion in the knee at 90°, pull, hip flexed, abduction and external rotation, CT in all cases post-reduction [USEMAP] Anterior disloc.- reduction - extension, internal rotation, adduction [USEMAP] After reduction •Pure dislocations - 54% - 2 weeks rest in a bad, progressive mobilization without weight, after 6 weeks step by step weight •With fracture of acetabulum /except central dislocation/ 36%, the most frequently fr. of posterior wall – osteosyntesis, or traction 2-3w, gradual weight with crutches after 8-12w. •With fracture of femur -10% - depends on type of fracture • [USEMAP] Prognosis •Threat of avascular necrosis of femoral head - 20%, after 12h 50% •Risk of posttraumatic coxartrosis •Paraarticular calcifications, osifications. •Risk of injury of n.ischiadicus and n.femoralis. • [USEMAP] Fractures of proximal femur •Head fractures •Neck fractures • -mediocervical (subcapital - intracapsular) • -laterocervical (basicervical - extracapsular) •Trochanteric /pertrochanteric, intertrochanteric/ fractures •Subtrochanteric fractures •Isolated fractures of trochanters • [USEMAP] Head fractures •Separate group of prox. femor. fr. • •Tangencial – flake-fracture, with posterior hip dislocation, without dislocation rare. • •Pipkin – 4 types /„Pipkin‘s fracture“/ - location. • •DG – x-ray, CT. • [USEMAP] Pipkin‘s classification Type I—femoral head fracture caudad to fovea capitis. Type II—femoral head fracture cephalad to fovea capitis. Type III—type I or II fracture with associated femoral neck fracture. Type IV—type I, II, or II fracture with associated acetabular fracture. [USEMAP] Therapy •aim – anatomical restoration of joint surface • •1. closed reduction of femur dislocation • •2. operation th. – depending on large of fragment /1cm2/ and location of defect • - fragment removal /open or artroscopy/, • - osteosyntesis /reduction and fixation of fragment/ using absorbable screws or glue, • - THA can be implanted in case of elderly. [USEMAP] Proximal femoral fractures – neck, per/intertrochanteric, subtrochanteric •Osteoporosis, pathological, minimal injury •Clin. – pain – hip /knee, hip possition – antalg. - external rotation, anteflexion, contraction, •Check neurovascular status •X ray – pelvis - whole /fr. Pelvis, other hip/, • - whole femur incl. Knee, • - CT ? • [USEMAP] Fractures of femoral neck • mediocervical (subcapital - intracapsular) – vitality of femoral head – interruption of vessels, compression – hematom, dislocation. • • laterocervical (basicervical - extracapsular) • • • [USEMAP] Femoral neck fractures - – classifications pauw Kopie%20-%20Garden Pauwels - I. – less than 30st., II. 30-70st, III. More than 70st. - mechanické poměry - abdukční – valgozní 10%, addukční - 90% Garden – vitality of head [USEMAP] Treatment of mediocervical fractures •Conservative - Garden I – valgus impacted • •Osteosyntesis - DHS, spongios screws, alternativly – PF – young /50y/ all types, older Garden II. • •Alloplastic – Garden III. a IV., depending on age total hip replacement - THA or hemiartroplasty - CKP /lifetime TEP 15y, CKP 5y/ Osteosyntesis – optimal time 6 - 12h /releasing of vessels – reduction, decompression of intracapsular haematoma/ Practice? - Risk of head necrosis - up to 30% dhs subkap zhojeno [USEMAP] •Hemiartroplasty •THA [USEMAP] Treatment of laterocervical – basicervical fractures •Extracapsular fr.– minimal risk of head necrosis, like per/intertrochatneric fractures •Osteosyntesis - PFN, DHS, rarely THA. [USEMAP] Inter-trochanteric fractures •Stabil X instabil - the most important is thick medial cortex (Adams‘s arch) AO [USEMAP] Treatment of per/intertrochanteric fractures •PFN •Gama nail •DHS – compresion hip screw • •Blade plates (95 st., 130 st.) •Enders rods /rarely/ -corect reduction -restoration of lenth and axis of limb -reduction of external rotation deformity -stabile osteosyntesis and early mobility of patient pfn7 [USEMAP] Fixation of intertrochanteric fracture with Dynamic (compression) Hip Screw [USEMAP] Fixation of introchanteric fracture with PFN / Gamma nail [USEMAP] 041_pac 042_pac DHS osteosyntesis of pertrochanteric fracture [USEMAP] Subtrochanteric fractures •Between the lesser trochanter and isthmus of the femoral canal •within 5 cm of the distal extent of the lesser trochanter •difficult reduction •Plating – open reduction, DHS, DCS •Nailing – more stabile, closed/open reduction, • - PFN • - gama nail • - antegrade nail proximaly locked in reconstruction mode (Reconstruction nail) • rek hr ap [USEMAP] •Nailing / Plating • 034_pac 031_pac [USEMAP] Open reduction and nailing [USEMAP] 012_pac 011_pac Failure of DHS plate [USEMAP] rek rek After change of DHS osteosynthesis to nail [USEMAP] Proximal femoral fractures •Reduction (traction) - analgezie, prevent of head ischemie, •prevention of thrombembolism •Acute operation /„vital indication“/ •Antibiotic profylaxis (one dose/24h) •Physiotherapy from 1st pooperative day • [USEMAP] Femoral shaft fracture •Usually are associated with considerable soft-tissue damage. •Blood loss of 2 to 3 units /1000-2000ml/ •high incidence of associated injury in the same extremity - fractures of the femoral neck, posterior fracture-dislocations of the hip, tears of the collateral ligaments of the knee, and osteochondral fractures involving the distal femur or patella and fractures of the tibia. [USEMAP] •X – ray – to view the joint above and the joint below the fracture •Treatment – operative - closed antegrade interlocking nailing - with or without reaming of the canal using flexible reamers • - plates (LCP), external fixator [USEMAP] Temporary immobilization [USEMAP] Nailing [USEMAP] Complications •Associated vascular and nerve damage, especially a transient peroneal or pudendal nerve palsy, is not uncommon - generally associated with excessive or prolonged traction. •Shortening and malrotation of the extremity frequently occur , even with intramedullary nailing. Slight shortening is associated with earlier fracture union, and shortening up to 0.5 inch should be accepted without hesitation. •Skin breakdown over bony prominences and pin track infections are complications of traction. •Infection is extremely rare with the closed nailing technique . •Nonunion occurs in approximately 1% of fractures treated with nailing. This problem is easily managed with nail removal, reaming, and repeat nailing. Healing complications are more common when small-diameter nails are used. •Rotational malunion occurs in 10% to 20% of patients; the deformity is generally external rotation . •Weakness of the abductor muscles and hip pain can occur in one third of patients. •Knee injuries are common after femoral shaft fractures . • [USEMAP] Distal femoral fractures •about 7% of all femur fractures. •If hip fractures are excluded, one-third of femur fractures involve the distal portion. •high incidence in young adults from high-energy trauma, in the elderly from minor falls. •In 5% to 10% - Open fractures • [USEMAP] Distal femoral fracture •Associated with osteoporosis •Dislocation - dorsal angulation – m.triceps surae •Sharp bony spike •Vascular damage 2% • [USEMAP] Distal femoral fractures AOD201_13 AOD201_14 AOD201_15 [USEMAP] Examine •Clin. – neurovascular status, skin and soft tissues •X – ray •CT [USEMAP] Nonoperative treatment •rarely •nondisplaced or incomplete fractures, impacted stable fractures in elderly patients – fixation •displaced - 6- to 12-week period of skeletal traction followed by bracing – risk • of varus and internal rotation deformity, knee stiffness, long bed rest • [USEMAP] Operative treatment • •Screws •DCS plate •Distal femoral nail •LCP – LISS •External fixation [USEMAP] Osteosyntesis LCP LISS a1 b1 [USEMAP] Retrograde nailing – Open Reduction Internal Fixation /ORIF/ [USEMAP] DFN – periprostetic fr., after 6m 1 2 0207d 0207c [USEMAP] Open fracture of distal femur, external fixation [USEMAP] [USEMAP] Distal femoral fracture Associated Vascular Injury •The incidence about 2%. •If arterial reconstruction is necessary, it should be done before definitive skeletal stabilization. •Reduction of the fracture and temporary fixation with an external fixator or femoral distractor before vascular repair should be considered. •Definitive fracture management can proceed after the vascular procedure if the patients condition allows. •Fasciotomy of the lower leg should be performed in all cases. • [USEMAP] Patellar fractures [USEMAP] Mechanism of injury •Direct: Displacement is typically minimal - preservation of the medial and lateral retinacular expansions. Abrasions or open injuries are common. Active knee extension may be preserved. • •Indirect (most common): This is secondary to forcible quadriceps contraction while the knee is in a semiflexed position The degree of displacement of the fragments suggests the degree of retinacular disruption. Active knee extension is usually lost. • •Combined direct/indirect mechanisms: These may be caused by trauma in which the patient experiences direct and indirect trauma to the knee, such as in a fall from a height. • [USEMAP] Clinical evaluation •Active knee extension should be evaluated to determine injury to the retinacular expansions. This may be aided by decompression of hemarthrosis or intraarticular lidocaine injection. • •Associated lower extremity injuries may be present in the setting of high-energy trauma. The physician must carefully evaluate the ipsilateral hip, femur, tibia, and ankle, with appropriate radiographic evaluation, if indicated. [USEMAP] Nonoperative treatment •Nondisplaced or minimally displaced (2- to 3-mm) fractures with minimal articular disruption (1 to 2 mm). This requires an intact extensor mechanism. • •A cylinder cast or knee immobilizer is used for 4 to 6 weeks. Early straight leg raising and isometric quadriceps strengthening exercises should be started within a few days. Weight bearing after 3-4 weeks, active flexion 4+w /x-ray/ • [USEMAP] Operative treatment •ORIF - open reduction and internal fixation include >2-mm articular incongruity, >3-mm fragment displacement, or open fracture. •There are multiple methods of operative fixation, including tension banding (using parallel longitudinal Kirschner wires or cannulated screws) as well as circumferential cerclage wiring. Retinacular disruption should be repaired at the time of surgery. •Postoperatively, the patient should be placed in a splint for 3 to 6 days until skin healing, with early institution of knee motion. The patient should perform active assisted range-of-motion exercises, progressing to partial and full weight bearing by 6 weeks. •Severely comminuted or marginally repaired fractures, particularly in older individuals, may necessitate immobilization for 3 to 6 weeks. •Patellectomy – partial / total - comminutive fractures, Reattachment of the quadriceps or patellar tendon, Repair of medial and lateral retinacular injuries , long leg cast at 10 degrees of flexion for 3 to 6 weeks. [USEMAP] Osteosynthesis of patellar fracture •Types of oteosynthesis •Dynamic tension band – produces increased compression with motion • [USEMAP] Děkuji za pozornost [USEMAP]