Lower Extremity Trauma

Lower Extremity Trauma

Lower Extremity Trauma M4 Student Clerkship UNMC Orthopaedic Surgery Department of Orthopaedic Surgery and Rehabilitation 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 Epidemiology

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

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 adduction and 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 with PT/OT 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 Femoral Head Fractures Treatment Options Type I Nonoperative: non-displaced ORIF if displaced Type II: ORIF Type III: ORIF of both fractures

Type IV: ORIF vs. hemiarthroplasty Femoral Neck Fractures Garden Classification I Valgus impacted II Non-displaced III Complete: Partially Displaced

IV Complete: Fully Displaced I II III IV Functional Classification

Stable (I/II) Unstable (III/IV) Femoral Neck Fractures Treatment Options Non-operative Very limited role Activity modification Skeletal traction Operative

ORIF Hemiarthroplasty (Endoprosthesis) Total Hip Replacement Hemi ORIF THR Femoral Neck Fractures Young Patients

Urgent ORIF (<6hrs) Elderly Patients ORIF possible (higher risk AVN, nonunion, and failure of fixation) Hemiarthroplasty Total Hip Replacement Intertrochanteric Hip Fx Intertrochanteric Femur Fracture

Extra-capsular femoral neck To inferior border of the lesser trochanter Intertrochanteric Hip Fx Intertrochanteric Femur Fracture Physical Findings: Shortened / ER Posture Obtain Xrays: AP Pelvis,

Cross table lateral Intertrochanteric Hip Fx 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 Intertrochanteric Hip Fx Stable Unstable Reverse Obliquity Intertrochanteric Hip Fx Treatment

Options Stable: Dynamic Hip Screw (2-hole) Unstable/Reverse: IM Recon 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 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 Knee Dislocations High association of injuries Ligamentous Injury ACL, PCL, Posterolateral Corner LCL, MCL Vascular Injury Intimal tear vs. Disruption Obtain ABIs (+) Arteriogram

Vascular surgery consult with repair within 8hrs Peroneal >> Tibial N. injury 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 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 +/- traction films CT scan (after ex-fix if appropriate) Schatzker Fxs Classification of Plateau

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, >5mm articular stepoff Non-operative in

non-displaced stable fractures or patients with poor surgical risks 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

ABCS Associated Injuries Tetanus Antibiotics Fixation Johner and Wruhs Classification 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 Tibial Shaft Fractures Management of Open Fx Soft Tissues ER: initial evaluation wound covered with sterile dressing and leg splinted, tetanus prophylaxis and appropriate antibiotics OR: Thorough I&D

undertaken within 6 hours with serial debridements as warranted followed by definitive soft tissue cover 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 Tibial Shaft Fractures 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 Pilon 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 Treatment Restore Articular Surface Minimize Soft Tissue Injury Establish Length Avoid Varus Collapse Treatment

Goals 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 weightbearing skeletal injury Incidence of ankle fractures has doubled since the 1960s 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? Patients 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) Ankle Fractures AP Ankle Tibiofibular overlap <10mm is abnormal and implies syndesmotic injury

Tibiofibular clear space >5mm is abnormal implies syndesmotic injury Talar tilt >2mm is considered abnormal 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

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) 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: WBAT in short leg cast or CAM boot for 4-6 weeks Repeat x-ray at 710 days to r/o interval displacement Ankle Fractures Indications care:

for operative 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 Ankle Fractures Most common weightbearing skeletal injury

Incidence of ankle fractures has doubled since the 1960s 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? Patients 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)

Ankle Fractures AP Ankle Tibiofibular overlap <10mm is abnormal and implies syndesmotic injury Tibiofibular clear space >5mm is abnormal implies syndesmotic injury

Talar tilt >2mm is considered abnormal 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 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) 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: WBAT in short leg cast or CAM boot for 4-6 weeks Repeat x-ray at 710 days to r/o interval

displacement Ankle Fractures Indications care: for operative

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

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