Lower limb fractures and dislocation

1. Lower limb fractures and dislocation PRESENTED BY JASIM HASAN

2. Learning outcome: The student should be able to: • Discuss on the mechanism, clinical presentation, classification, radiological findings, and its complications of fractures and joint dislocation • Derive treatment option of the common lower limb fractures and joint dislocation

3. Contents: • FRACTURE NECK OF FEMUR • INTERTROCHANTERIC FRACTURE • HIP JOINT DISLOCATION • FEMUR SHAFT FRACTURE • DISTAL FEMUR FRACTURE • KNEE JOINT DISLOCATION • PATELLA FRACTURE • TIBIAL PLATEAU FRACTURE

4. CONT’: • TIBIA SHAFT FRACTURE • MALLEOLI FRACTURE • TALUS FRACTURE • CALCANEUM FRACTURE

5. Fracture neck of femur • Common in elderly following fall (osteoporosis) • Young adult is due to high energy impact such as road traffic accident • May accompanied hip joint dislocation (high impact injury) Demonstrated radiological (AP view of hip joint) as: • Loss of Shenton’s line • Disruption of proximal femur trabecula

6. Classification: • Garden’s classification (4 stages) for femur neck fracture • Help to determine the management and predict the prognosis on complication (avascular necrosis of the femoral head)

7. Garden’s classification

8. Anatomical classification: • Also can describe the pattern of neck fracture • Subcapital region • Transcervical region • Basal region • Prognosis for AVN worsen in subcapital and transverse fracture

9. Radiological features of neck of femur fracture Shenton’s line

10. Complication: • Avascular necrosis of the femur head • Non-union of the fracture • General complications following prolong bedridden for conservative treatment (bedsore, DVT, pneumonia, stiffness)

11. Treatment: • Depend on the age of the patient, patient’s health and fracture stages & duration Non-operative reserve for: • Poor health (unfit for surgery) patient • Require on Traction for 3 – 6 weeks then start ambulate

12. Cont’: Operative treatment is the main goal: • Younger age group with acute # and elderly with impacted # (preserved the head) usage of fracture fixation devices eg. Screw fixation, Dynamic Hip Screw • Elderly patient with displaced # or chronic # subjected to hip replacement (hemiarthroplasty or total arthroplasty of the hip joint)

13. Intertrochanteric fracture • Commonly occur in elderly patient (osteoporosis) following trivial fall • Extension to subtrochanteric region • May presented as comminuted fracture pattern

14. Radiograph shows intertrochanteric fracture of the femur

15. Complications: • Mal-union of the fracture • Failure in fixation for the fracture due to osteoporotic bone • General complications following prolong bedridden

16. Treatment • Operative is the main goal except unfit patient for anaesthesia or extreme osteoporotic bone Choices of implant for fracture fixation: • Dynamic Hip Screw • Proximal femoral nail (PFN)

17. Fixation of fracture intertrochanteric fracture

18. Hip joint dislocation • Direction: posterior is more common than anterior • Mechanism: ‘dash-board’ injury • Limb attitude: • Posterior dislocation (flexed, adducted, internally rotated, short limb) • Anterior dislocation (flexed, externally rotated, abducted) • Association with acetebular fractures of femoral head fractures

19. Left side Radiograph shows left hip dislocation

20. Complications: • Sciatic nerve injury leading muscle paralysis and loss of sensory below the knee • Prolong dislocation can also result in avascular necrosis of the femoral head

21. Treatment • Emergency CMR under sedation • Failure in CMR  open reduction

22. Femoral shaft fractures • Area that is well padded with muscles leading to fracture displacement and difficulty in CMR and maintain the reduction • Associated with soft tissue injury due to high-energy injury risk of getting compartment syndrome • Long bones – segmental # • Occasionally associated with # neck of femur

23. Radiographs show femur shaft fractures Distal 1/3 Proximal 1/3 supracondyalar

24. Complication • Vascular injury (femoral artery) • Fat embolism • Delayed and non-union of the fracture • Mal-union of the fracture • Joint stiffness (knee)

25. Treatment • Less preference for non-operative treatment (as the bone is weight bearing region) in adult Operative fracture fixation used : • Intramedullary-Locking-Nail • Plating (DCP)

26. Intramedullary locking nail

27. Distal femur #: Supracondylar & intercondylar • Supracondylar # can be isolated or combination with intercondylar # • Result from high energy force • Risk of vascular injury (femoral artery) • Intercondylar extension may involved articular region of the knee

28. Complications • Joint stiffness and arthrosis if involve the articular region • Risk of femoral artery injury

29. Treatment • Open Reduction Internal Fixation is a goal standard treatment Fixation devices: • Angled blade plate • CDS (condylar dynamic screw) • Supracondylar inter-locking nail • Buttress plating (locking plate)

30. Angled blade plate for fixation of supracondylar fracture of the femur

31. Knee joint dislocation • Result from violence injury force • Involve more than two of knee ligaments injury • Can presented as ‘self-reduction’ joint dislocation • Associated with popliteal vessel injury and common peroneal nerve injury • Urgent attention for vascular assessment

32. Radiographs show anterior dislocation of the knee

33. Risk of vascular injury • Transected or thrombosis. • Vascular assessment or surveillance • Angiogram as indicated

34. Directions of dislocation • Reference to the position of tibia • Anteromedial dislocation (risk of associated injury of popliteal artery) • Posterolateral dislocation (highly associated with transected popliteal artery)

35. artery

36. Complications • Neurovascular injury • Knee ligaments injury (result in joint instability) • Stiffness of the joint • Arthrosis formation following cartilage damage

37. Treatment • Immediate reduction and immobilization • Artery exploration and repair in the evidence of arterial injury • Immobilization in cast or external fixation • Ligaments repair or reconstruction for multiple ligaments injury resulting in instability

38. Tibial plateau fractures • Mechanism: varus or valgus force combined with axial loading • Also known as ‘bumper fracture’ • Tibial condyle can be crushed or split • Presentation: haemathrosis, instability, associated neurovascular injury

40. Types of TP # • Simple split lateral condyle • Depressed, comminuted lateral condyle • Crushed comminuted lateral condyle • Split medial condyle • Bicondylar fractures • Bicondylar and subcondylar

42. Complications • Compartment syndrome • Joint stiffness • Deformity • arthrosis

43. Treatment Undisplaced or minimally displaced • Traction until swelling subsided, apply cast immobilization Displaced and depressed • Open reduction and internal fixation (buttress plate, inter-fragmentary screw) • May need bone grafting in depressed fractures

44. Patella fractures • Direct injury (dash board, direct fall onto the knee) produced ‘stellate’ fracture • Indirect injury (forced flexion knee) produce avulsion type or simple transverse pattern • Loss of extensor mechanism • Haemathrosis

45. Complications • Joint stiffness • Patellofemoral arthrosis • reduced knee extensor mechanism

46. Treatment Undisplaced fracture • Cylinder cast immobilization for 6 weeks Displaced fracture • ORIF (tension band wiring) Severely comminuted • Cerclage wiring or patellectomy

47. Tibial shaft fractures • Proximal, middle, distal region • Compartment syndrome (proximal 1/3) • Affecting union (distal 1/3) • Spiral, oblique (indirect force) • Transverse, comminuted (direct force) • With or without fibular shaft #

48. Radiographs show tibial shaft fracture

49. Complications • Compartment syndrome • Malunion (leading to shortening and arthrosis) • Nonunion

50. Treatment Acceptable displacement with less comminuted (stable) • Apply Full Length POP immobilization for 6 weeks Comminuted, segmental (unstable reduction alignment) • Internal fixation (ILN, Plating)