Lower Extremity Trauma Trauma Hospital, Brno Trauma Departement, Medical Faculty, Masaryk Univerzity, Brno Lower Extremity Trauma ◼ Hip Fractures / Dislocations ◼ Femur Fractures ◼ Patella Fractures ◼ Knee Dislocations ◼ Tibia Fractures ◼ Ankle Fractures Hip Fractures ◼ Hip Dislocations ◼ Femoral Head Fractures ◼ Femoral Neck Fractures ◼ Intertrochanteric Fractures ◼ Subtrochanteric Fractures ◼ 250,000 Hip fractures annually – Expected to double by 2050 ◼ At risk populations – Elderly: poor balance & vision, osteoporosis, inactivity, medications, malnutrition – Young: high energy trauma Epidemiology Hip Dislocations ◼ Significant trauma, usually MVA ◼ Posterior: Hip flexion, IR, Add ◼ Anterior: Extreme ER, Abd/Flex Hip Dislocations ◼ Emergent Treatment: Closed Reduction – Dislocated hip is an emergency – Goal is to reduce risk of AVN and DJD – Allows restoration of flow through occluded or compressed vessels – Literature supports decreased AVN with earlier reduction – Requires proper anesthesia – Requires “team” (i.e. more than one person) Hip Dislocations ◼ Emergent Treatment: Closed Reduction – General anesthesia with muscle relaxation facilitates reduction, but is not necessary – Conscious sedation is acceptable – Attempts at reduction with inadequate analgesia/ sedation will cause unnecessary pain, cause muscle spasm, and make subsequent attempts at reduction more difficult Hip Dislocations ◼ Emergent Treatment: Closed Reduction ◼ Allis Maneuver – Assistant stabilizes pelvis with pressure on ASIS – Surgeon stands on stretcher and gently flexes hip to 90deg, applies progressively increasing traction to the extremity with gentle abduction + ext. rotation / adduction + internal rotation – Reduction can often be seen and felt Insert hip Reduction Picture Hip Dislocations ◼ Following Closed Reduction – Check stability of hip to 90deg flexion – Repeat AP pelvis – Judet views of pelvis (if acetabulum fx) – CT scan with thin cuts through acetabulum – R/O bony fragments within hip joint (indication for emergent OR trip to remove incarcerated fragment of bone) Hip Dislocations ◼ Following Closed Reduction – No flexion > 60deg (Hip Precautions) – Early mobilization – TTWB for 4-6 weeks – MRI at 3 months (follow risk of AVN) Femoral Head Fractures ◼ Concurrent with hip dislocation due to shear injury Femoral Head Fractures ◼ Pipkin Classification – I: Fracture inferior to fovea – II: Fracture superior to fovea – III: Femoral head + acetabulum fracture – IV: Femoral head + femoral neck fracture ◼ Treatment Options – Type I ▪ Nonoperative: non-displaced ▪ ORIF or extirpation if displaced – Type II: ORIF/TEP – Type III: TEP/ORIF of both fractures – Type IV: ORIF/hemiarthroplasty/TEP Femoral Head Fractures Femoral Neck Fractures ◼ Garden Classification – I Valgus impacted – II Non-displaced – III Complete: Partially Displaced – IV Complete: Fully Displaced ◼ Functional Classification – Stable (I/II) – Unstable (III/IV) I II III IV ◼ Treatment Options – Non-operative ▪ Very limited role ▪ Activity modification ▪ Skeletal traction – Operative ▪ ORIF ▪ Hemiarthroplasty (Endoprosthesis) ▪ Total Hip Replacement Femoral Neck Fractures ORIF Hemi THR Femoral Neck Fractures ◼ Young Patients – Urgent ORIF (<6hrs) ◼ Elderly Patients – ORIF possible (higher risk AVN, non-union, and failure of fixation) – Hemiarthroplasty – Total Hip Replacement Pertrochanteric Hip Fx ◼ Pertrochanteric Femur Fracture – Extra-capsular femoral neck – To inferior border of the lesser trochanter Pertrochanteric Hip Fx ◼ Pertrochanteric Femur Fracture – Physical Findings: Shortened / ER Posture – Obtain Xrays: AP Pelvis, Cross table lateral ◼ Classification – # of parts: Head/Neck, GT, LT, Shaft – Stable ▪ Resists medial & compressive Loads after fixation – Unstable ▪ Collapses into varus or shaft medializes despite anatomic reduction with fixation – Reverse Obliquity Pertrochanteric Hip Fx Stable Reverse Obliquity Unstable Pertrochanteric Hip Fx Pertrochanteric Hip Fx ◼ Treatment Options – Stable: Dynamic Hip Screw – Unstable/Reverse: PFN, Gama Nail Subtrochanteric Femur Fx ◼ Classification – Located from LT to 5cm distal into shaft – Intact Piriformis Fossa? ◼ Treatment – IM Nail – Cephalomedullary IM Nail – ORIF Femoral Shaft Fx ◼ Type 0 - No comminution ◼ Type 1 - Insignificant butterfly fragment with transverse or short oblique fracture ◼ Type 2 - Large butterfly of less than 50% of the bony width, > 50% of cortex intact ◼ Type 3 - Larger butterfly leaving less than 50% of the cortex in contact ◼ Type 4 - Segmental comminution ▪ Winquist and Hansen 66A, 1984 Femoral Shaft Fx ◼ Treatment Options – IM Nail with locking screws – ORIF with plate/screw construct – External fixation – Consider traction pin if prolonged delay to surgery Femoral Shaft Fx Distal Femur Fractures ◼ Distal Metaphyseal Fractures ◼ Look for intra-articular involvement ◼ Plain films ◼ CT Distal Femur Fractures ◼ Treatment: – Retrograde IM Nail – ORIF open vs. MIPO – Above depends on fracture type, bone quality, and fracture location Distal Femur Fractures ◼ High association of injuries – Ligamentous Injury ▪ ACL, PCL, Posterolateral Corner ▪ LCL, MCL – Vascular Injury ▪ Intimal tear vs. Disruption ▪ US → CT Angio ▪ Vascular surgery consult with repair within 8hrs – Peroneal >> Tibial N. injury Knee Dislocations Patella Fractures ◼ History – MVA, fall onto knee, eccentric loading ◼ Physical Exam – Ability to perform straight leg raise against gravity (ie, extensor mechanism still intact?) – Pain, swelling, contusions, lacerations and/or abrasions at the site of injury – Palpable defect Patella Fractures ◼ Radiographs – AP/Lateral/Sunrise views ◼ Treatment – ORIF if ext mechanism is incompetent – Non-operative treatment with brace if ext mechanism remains intact Patella Fractures Tibia Fractures ◼ Proximal Tibia Fractures (Tibial Plateau) ◼ Tibial Shaft Fractures ◼ Distal Tibia Fractures (Tibial Pilon/Plafond) Tibial Plateau Fractures ◼ MVA, fall from height, sporting injuries ◼ Mechanism and energy of injury plays a major role in determining orthopedic care ◼ Examine soft tissues, neurologic exam (peroneal N.), vascular exam (esp with medial plateau injuries) ◼ Be aware for compartment syndrome ◼ Check for knee ligamentous instability Tibial Plateau Fractures ◼ Xrays: AP/Lateral ◼ CT scan (after ex-fix if appropriate) ◼ Schatzker Classification of Plateau Fxs Lower Energy Higher Energy Tibial Plateau Fractures ◼ Treatment – Spanning External Fixator may be appropriate for temporary stabilization and to allow for resolution of soft tissue injuries Insert blister Pics of ex-fix here Tibial Plateau Fractures ◼ Treatment – Definitive ORIF for patients with varus/valgus instability, >2-5mm articular stepoff – Non-operative rare, in non-displaced stable fractures or patients with GA contraindication Tibial Shaft Fractures ◼ Mechanism of Injury – Can occur in lower energy, torsion type injury (e.g., skiing) – More common with higher energy direct force (e.g., car bumper) – Open fractures of the tibia are more common than in any other long bone Tibial Shaft Fractures ◼ Open Tibia Fx ◼ Priorities – ABC’S – Associated Injuries – Soft tissues – Tetanus – Antibiotics – Fixation Tibial Shaft Fractures ◼ Gustilo and Anderson Classification of Open Fx – Grade 1 ▪ <1cm, minimal muscle contusion, usually inside out mechanism – Grade 2 ▪ 1-10cm, extensive soft tissue damage – Grade 3 ▪ 3a: >10cm, adequate bone coverage ▪ 3b: >10cm, periosteal stripping requiring flap advancement or free flap ▪ 3c: vascular injury requiring repair Tibial Shaft Fractures ◼ Tscherne Classification of Soft Tissue Injury – Grade 0- Negligible soft tissue injury – Grade 1- Superficial abrasion or contusion – Grade 2- Deep contusion from direct trauma – Grade 3- Extensive contusion and crush injury with possible severe muscle injury ◼ Management of Open Fx Soft Tissues – ER: initial evaluation → wound covered with sterile dressing and leg splinted, tetanus prophylaxis and appropriate antibiotics – OR: Thorough tratment undertaken within 6 hours with serial debridements as warranted followed by definitive soft tissue cover Tibial Shaft Fractures Tibial Shaft Fractures ◼ Definitive Soft Tissue Coverage – Proximal third tibia fractures can be covered with gastrocnemius rotation flap – Middle third tibia fractures can be covered with soleus rotation flap – Distal third fractures usually require free flap for coverage Tibial Shaft Fractures ◼ Treatment Options – IM Nail – ORIF with Plates – External Fixation – Cast or Cast-Brace - rare ◼ Advantages of IM nailing – Lower non-union rate – Smaller incisions – Earlier weightbearing and function – Single surgery Tibial Shaft Fractures ◼ IM nailing of distal and proximal fx – Can be done but requires additional planning, special nails, and advanced techniques Tibial Shaft Fractures ◼ Fractures involving distal tibia metaphysis and into the ankle joint ◼ Soft tissue management is key! ◼ Often occurs from fall from height or high energy injuries in MVA ◼ “Excellent” results are rare, “Fair to Good” is the norm outcome ◼ Multiple potential complications Tibial Pilon Fractures ◼ Initial Evaluation – Plain films, CT scan – Spanning External Fixator – Delayed Definitive Care to protect soft tissues and allow for soft tissue swelling to resolve Tibial Pilon Fractures Tibial Pilon Fractures ◼ Treatment Goals – Restore Articular Surface – Minimize Soft Tissue Injury – Establish Length – Avoid Varus Collapse ◼ Treatment Options – IM nail with limited ORIF – ORIF – External Fixator Tibial Pilon Fractures ◼ Complications – Mal or Non-union (Varus) – Soft Tissue Complications – Infection – Potential Amputation Ankle Fractures ◼ Most common weight-bearing skeletal injury ◼ Incidence of ankle fractures has doubled since the 1960’s ◼ Highest incidence in elderly women – Unimalleolar 68% – Bimalleolar 25% – Trimalleolar 7% – Open 2% ◼ Osseous Anatomy ◼ Lateral Ligamentous Anatomy ◼ Medial Ligamentous Anatomy ◼ Syndesmosis Anatomy Ankle Fractures ◼ History – Mechanism of injury – Time elapsed since the injury – Soft-tissue injury – Has the patient ambulated on the ankle? – Patient’s age / bone quality – Associated injuries – Comorbidities (DM, smoking) Ankle Fractures ◼ Physical Exam – Neurovascular exam – Note obvious deformities – Pain over the medial or lateral malleoli – Palpation of ligaments about the ankle – Palpation of proximal fibula, lateral process of talus, base of 5th MT – Examine the hindfoot and forefoot Ankle Fractures ◼ Radiographic Studies – AP, Lateral, Mortise of Ankle (Weight Bearing if possible) – AP, Lateral of Knee (Maissaneve injury) – AP, Lateral, Oblique of Foot (if painful) ◼ AP Ankle – Tibiofibular overlap ▪ <10mm is abnormal and implies syndesmotic injury – Medial clear space ▪ >4mm is abnormal implies injury Ankle Fractures ◼ Ankle Mortise View – Foot is internally rotated and AP projection is performed – Abnormal findings: ▪ Medial joint space widening ▪ Talocural angle <8 or >15 degrees (compare to normal side) ▪ Tibia/fibula overlap <1mm Ankle Fractures ◼ Lateral View – Posterior malleolar fractures – Anterior/posterior subluxation of the talus under the tibia – Displacement/Shortening of distal fibula – Associated injuries Ankle Fractures Ankle Fractures ◼ Classification Systems (Lauge-Hansen) – Based on cadaveric study – First word refers to position of foot at time of injury – Second word refers to force applied to foot relative to tibia at time of injury Ankle Fractures ◼ Classification Systems (Weber-Danis) – A: Fibula Fracture distal to mortise – B: Fibula Fracture at the level of the mortise – C: Fibula Fracture proximal to mortise Ankle Fractures ◼ Initial Management – Closed reduction (conscious sedation may be necessary in pediatrics) – AO splint – Delayed fixation until soft tissues stable – Pain control – Monitor for possible compartment syndrome in high energy injuries Ankle Fractures ◼ Indications for non-operative care: – Nondisplaced fracture with intact syndesmosis and stable mortise – Less than 3 mm displacement of the isolated fibula fracture with no medial injury – Patient whose overall condition is unstable and would not tolerate an operative procedure ◼ Management: – NWB in short leg cast or CAM boot for 4-6 weeks – Repeat x-ray at 7–10 days to r/o interval displacement Ankle Fractures ◼ Indications for operative care: – Bimalleolar fractures – Trimalleolar fractures – Talar subluxation – Articular impaction injury – Syndesmotic injury ▪ Beware the painful ankle with no ankle fracture but a widened mortise… check knee films to rule out Maissoneuve Syndesmosis injury. Ankle Fractures ◼ ORIF: – Fibula ▪ Lag Screw if possible + Plate ▪ Confirm length/rotation – Medial Malleolus ▪ Open reduce ▪ 4-0 cancellous screws vs. tension band – Posterior Malleolus ▪ Fix if >30% of articular surface – Syndesmosis ▪ Stress after fixation ▪ Fix with 3 or 4 cortex screws